Skip to main content

Full text of "Edinburgh Medical Journal"

See other formats


This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project 
to make the world's books discoverable online. 

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject 
to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books 
are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. 

Marks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 
publisher to a library and finally to you. 

Usage guidelines 

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 

We also ask that you: 

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for 
personal, non-commercial purposes. 

+ Refrain from automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the 
use of public domain materials for these purposes and may be able to help. 

+ Maintain attribution The Google "watermark" you see on each file is essential for informing people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just 
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liability can be quite severe. 

About Google Book Search 

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web 



at |http : //books . google . com/ 



^ 



BOSTON 
MEDICAL LIBRARY 




IN THE 



Francis A.Countway 
Library of Medicine 



BOSTON 



!E 



EDINBURGH 



MEDICAL JOURNAL, 



THE MONTHLY JOURNAL OP MEDICINE 

JLMD 

THE EDINBURGH MEDICAL AND SURGICAL JOURNAL. 

VOL. X. 
JULY 1664 TO JUlf»*M4p. 




EDINBURGH: 

OLIVER AND BOYD, TWEEDDALE COURT. 

LONDON: SIMPKIN, MABSHALL, AND CO. 



MDCCCLXY. 



1 



y 



■DOIBUiaH : PBHTBO BT OUTm AMD BOTD, TWBEDDAXA OOUIT. 



ALPHABETICAL LIST 



CONTRIBUTORS OF ORIGINAL ARTICLES. 



Amderbon, Izbtt W., M.D., Kingston, Jftmaica. 
. Amnandale, Thomas, F.R.C.S.E., Assistant-Snrgeon to the Royal Infirmary, 

Edinboigh. 
Babtlbtt, Jobefh, L.R.C.P. Lond., M.R.C.S., London. 
Bell, Charles, M.D., F.R.C.F.E., Edinburgh. 
Bell, Joseph, M.D., F.R.C.P.E., AssiBtant-Surgeon, Surgical Clinical Wards, 

Royal Infirmary, Edinburgh. 
BoNNAR, George Lindsay, M.D., Cupar-Fife. 
Braidwood, Peter, M.D., Edinburgh. 
Browne, J. Crichton, M.D., Newcastle-upon-Tyne. 
Buchanan, George, M.D., Surgeon to the Royal Infirmary, Glasgow. 
Carmichael, Duncan, M.D., Buckie, Banffshire. 
Christie,' John, M.D., F.R.C.S.E., Lecturer on Midwifery, Aberdeen. 
CuTHiLL, James, M.D., Denny, Stirlingshire. 

Davidson, Andrew, L.R.C.P. & S. Edin., Antananarivo, Madagascar. 
Dickinson, W. H., M.D. Cantab., Assistant-Physician to the Hospital for 

Sick Children, London. 
Dix, John, M.R.C.S., Surgeon to the Hull and Sculcoates Infirmary. 
Duncan, J. Matthews, M.D., F.R.C.P.E., Physician and Clinical Lecturer 

on Diseases of Women, Royal Infirmary, Edinburgh. 
Duncan, John, M.D., F.R.C.S.E., Edinburgh. 
Fayrer, Joseph, M.D., F.R.C.S.E., First Surgeon and Professor of Surgery 

in the Bengal Medical College, Calcutta. 
FiNLAY, Robert, M.D., Edinburgh. 
Qamqee, Arthur, M.D., Assistant to the Professor of Medical Jurisprudence 

in the University of Edinburgh. 
Grbig, David, M.D., F.R.C.S.E., Dundee. 
Haldane, D. Rutherford, M.D., F.R.C.P.E., Physician to the Royal 

Infirmary, Edinburgh. 
Heath, George Y., M.B., M.R.C.S., Surgeon to the Newcastle Infirmary 

and Eye Infirmary. 
Hewan, Archibald, F.R.C.S.E., Medical Missionary at Old Calabar. 
Hjaltblin, John, M.D., Inspecting Medical Officer of Iceland. 



IV GONTBIBUTOBS OF ORIGINAL ARTICLES. 

Inolis, Andrew, M.D., F.R.C.S.E., Edinburgh. 

Keith, Thomas, M.D., F.R.C.S.E., Edinburgh. 

Kerr, William, Surgeon, Corresponding Member of the Medical and Physical 

Society of Calcutta, and of the Medico-Chirurgical Society of Glasgow. 
Ketchem, William, M.D., Suigeon to the Forfar Infirmary. 
Laycock, Thomas, M.D., F.R.C.P.E., Professor of the Practice of Medicine 

in the University of Edinburgh. 
Leslie, David, M.D., Tunbridge, Kent. 
Lock WOOD, A. P., Surgeon-Major, 2d Dragoons. 
Lyell, John, M.D., Newburgh, Fife. 

Macadam, Stevenson, Ph.D., F.R.S.E., Lecturer on Chemistry, Edinburgh. 
Maclaoan, Craig, M.D., M.R.C.P.E., Edinburgh. 
Maclaqan, Douglas, M.D., F.R.C.P.E., Professor of Medical Jurisprudence 

in the University of Edinburgh. 
M^Leod, EIenneth, Assistant Medical Officer, Durham County Asylum. 
Mitchell, Arthur, M.D., Deputy Commissioner in Lunacy for Scotland. 
MuNRO, W. Stuart, M.D., West Hartlepool. 
Parker, D. M*N., Halifax, Nova Scotia. 
Paterson, George, K. H., L.R.C.P.E., Balbeggie, Perthshire. 
Reid, John Watt, M.D., Surgeon, Royal Navy. 
Ringer, Sydney, M.D., M.R.C.P., Professor of Materia Medica, University 

College, London. 
Sanders, William R., M.D., F.R.C.P.E., Physician to the Royal Infirmary, 

Edinburgh. 
Simpson, Alexander R., M.D., M.R.C.P.E., Glasgow. 
Simpson, David James, M.D., Edinburgh. 
Skae, Francis, M.D., Edinburgh. 
Smith, John, M.D., F.R.C.S.E., Dental Surgeon to the Royal Infirmary, 

Edinburgh. 
Spence, James, F.R.C.S.E., Professor of Surgery in the University of 

Edinburgh. 
Stephenson, William, M.D., F.R.C.S.E., Extra Physician to the Royal 

Hospital for Sick Children, Edinburgh. 
Stewart, T. Grainger, M.D., F.R.C.P.E., Pathologbt to the Royal In- 
firmary, Edinburgh. 
Thin, George, M.D., formerly of Penicuik. 
Thomson, J. B., L.R.C.S.E., Resident Surgeon to the General Prison for 

Scotland, Perth. 
Tuke, John Batty, M.D., Medical Sapermtendent of Fife and Kinross 

Lunatic Asylum. 
TURNERy ROBERT, M.D., Keith. 
Turner, William, M.B. Lond., F.R.C.S.E., Senior Demonstrator of Anatomy 

in the University of Edinburgh. 
Veale, Henry, M.D., Assistant Surgeon, Royal ArtiUery. 
Watson, James, M.D., Newchang. 




■ ? r: y.-. -. Y AM ? i: t a r i u n 



THE 

EDINBUKGH 
MEDICAL JOUBNAL. 



$avt jffitnt 



ORIGINAL COMMUNICATIONS. 

Abticle I.— Surgical Cases. By James Spbnce, F.R.C.S., 
Member of the ^resident's Council, and one of the Examiners 
of the Bojal College of Surgeons, Edinburgh ; Surgeon and 
Lecturer on Clinical Surgery. Royal Infirmary; Lecturer on 
Surgery, Surgeons' HiJl, Edinourgh. 

(Bead before the Medico- Chirurgical Society, May 4, 1864.) 

1. Successful Case op Pbimart Amputation at the Hip-Joint. 

On the 3d of September 1863, Robert Davidson, aged 12 years, 
was thrown from a truck which had been suddenly set in motion, 
and fell in front of it, both wheels passing obliquely over the upper 
part of the left thigh just below the pelvis. The accident happened 
at the Melrose station, and the bov was seen almost immediately 
by Dr Clarkson, who adjusted the limb, and had him conveyed to 
his home at Newstead about a mile distant. About two hours 
afterwards, Drs Brown and Smith accompanied Dr Clarkson to see 
the case. The boy had recovered in a great measure from the 
shock, but his pulse was still very weak. On examination, there 
was found a large contused flesh wound at the upper and inner 
part of the left thigh, exposing the muscles, which were much torn 
and bruised, and allowing the finger to be passed deeply into the 
tissues of the limb. The femur at and below the trochanters was 
felt to be much shattered. The foot was cold, and pulsation in the 
popliteal and tibial arteries extremely weak, but there had been no 
great amount of blood lost. 

As it appeared to the medical attendants that the boy's only 
chance of life was removal of the limb by amputation at the hip- 
joint, I was telegraphed for, and arrived at the patient's house about 
9 P.M. On examination of the injury, the contused and lacerated 

VOL. X.— NO. I. A 



2 SUUGICAL CASES BY MR SPENCE. [JULT 

state of the soft parts, the shattered condition of the femur, and the 
consideration of the great force by which the injury had been 
caused, left no doubt as to the practice to be pursued. I at once 
coincided in the opinion which his medical attendants had expressed, 
although, from the depressed state of the young patient, and the 
proximity of the injury to the trunk, the chances of success seemed 
very small. 

The boy's parents having given their consent, I proceeded to 
perform the operation under circumstances not the most favourable. 
The room was small, and the only light procurable was from a small 
lamp on the mantelpiece, and two small candles held by a non- 
pro^sional assistant ; a wax taper I had brought with me was kept 
m reserve for exigencies. I had brought Lister's abdominal com- 
pressor, but as it could not be applied so as to command thoroughly 
the circulation, Dr Smith took cnarge of compressing the common 
femoral on the brim of the pelvis, and I instructed one of the 
patient's friends how to command the bleeding from the posterior 
nap, by grasping it with one hand and pressing a large sponge 
upon its surface. Dr Brown took charge of the movements of the 
limb, whilst Dr Clarkson administered the chloroform. When the 
boy was brought under its influence, I entered my knife between 
the trochanter major and the anterior superior spine of the ilium, 
and carrying it obliquely across the thigh, brought the point out a 
little above the tuberosity of the ischium, cutting a short anterior 
flap. Dr Brown then rotated and depressed the limb, with the 
view of facilitating disarticulation ; but owing to the shattered state 
of the femur, this movement did not produce the desired effect. 
Fortunately, however, this caused no great delay, for my knife had 
opened the joint in passing' across the limb ; and by grasping the 
upper broken fragment of the bone, so as to project the head, I com- 
pleted the disarticulation, and cut as large a posterior flap as I 
could obtain from the uninjured parts. Some vessels on the poste- 
rior flap were first secured, and then the great vessels in the anterior 
flap, — the vein beilig included in a ligature. I then removed some 
contused and doubtfiil-looking portions of muscle. After all bleed- 
ing had been arrested, the flaps were brought tocether with sutures; 
and considering the nature of the parts from which the flaps were 
formed, they fitted tolerably well. The stump was then oressed, 
and the patient placed in bed, hot bottles applied, and some stimulus 
given, as he was very weak. He lost very little blood during the 
operation, as I ascertained by carefriUy collecting the blood from 
the stone floor, when it was found to amount to less than half a 
small teacupful ; and altogether, with what was in the sponges, to 
about five ounces at most. After waiting till the little patient had 
completely rallied from the chloroform, and had got an opiate 
administered. I left him in the charge of Dr Smith, who remained 
with him all night, and to whom I am indebted for the following 
report of the progress of the case : — 



1864.] 'surgical CASES BT MB 8FEKCE. 3 

Examination of Limb after Removal. — On examination of the 
limb after removal, the femur, from the large trochanter downwards 
for about two inches, was found to be broken into numerous frag- 
ments, the ragged edges of which were embedded in the surround- 
ing soft parts. The muscles and other structures were much bruised 
and torn, but there was no direct injury to the large vessels or nerves. 

4th September. — During the night, patient was very restless and 
delirious. Pulse 134, weak. A little brandy and water was 
administered at intervals, but was vomited. No reactionary haemop- 
rhage of any consequence. Vespere. — Still restless, with delirium. 
Pulse 130. To have opiate with a few drops tinct. mur. ferr. 

5th. — Restless night Pulse 130, very weak and thready. Sunken 
aspect of countenance. Beef-tea, brandy, and milk given in small 
quantities frequently. 

6^, — ^Bather better. Slept a little. Less delirium. Pulse 108, 
stronger. Wound has healthy appearance, except at the bruised 
part of the flap, which looks slougny. 

7th. — Pulse 108. Sloughing action extending slightly on poste- 
rior flap. Foetid sero-purulent discharge. Chloride of soda loticm. 
Opiate. 

8th. — ^Pulse 90. No delirium. Line of demarcation formed^ 
showing slouch, rather exceding a square inch in extent. Purulent 
discharge copious and less foetid. 

9th. — All the stitches removed, and the flaps brought together 
as well as possible by strips of plaster. Pulse 100. 

12th. — Sloughs separated. An attack of diarrhoea. Slight delirr 
ium. Opiate. 

14th. — Pulse 108. Diarrhoea less. Stump looking healthy. 
Diet for the most part milk, beef-tea, wine, witn a little brandy. 

16<A.— Doing well. 

20^. — ^Pulse has risen to 120. Had a restless night with delir- 
ium. Raw surface of stump covered with patches of whitish semi- 
translucent membrane of pretty tough consistence. Copious purulent 
discharge. Stimulants given in increased quanti^.^ 

2l8t. — Pulse 120. Occasional delirium. Wound has same 
appearance. 

23d. — ^Pttlse 118. Wound has less of its diphtheritic-looking 
covering. 

27th. — Stump looks hedthy, and is cicatrizing round the edges. 
Dressed with sulphate of zinc lotion. Pulse still high, 116. Sleeps 
well. Appetite mdifferent. 

1st Octoker. — Pulse 110. Doing well. 

4^.— Pulse 102. 

From this time recovery was slow but uninterrupted. The patient 
gained strength gradually, with the aid of tonics, wine, etc. The 
femoral ligature did not fall off till 4th November, two months 

^ Dr Brown informs me that diphtheria was prevailing in the diBtrict at the tiiue. 



y 



4 0UBO1CAL CASES BT MB SPENCE. [JULT 

after the operatioD, having evidentlj been retained for some time 
after its separation from Uie vessel by the granulations surround- 
ing it. By the middle of December the stump was healed^ with 
the exception of a mere spot. Two or three weeks later this also 
had closed, and the patient was able to move about wilh the aid 
of crutches. 

H&marka. — I have thought this case would be interesting to the 
Society, because successful results in cases of amputation at the 
hip-iomt are rare, and in primary amputations, exceedingly so. In 
the last edition of " Cooper's Surgical Dictionary," it is stated that 
there have been six cases of primary amputation at the hip per- 
formed in Great Britain since 1838, and all of them proved fatal. 
In the Crimea fourteen amputations at the hip-joint were performed 
by British surgeons for injury, and not one recovered ; and in the 
Punjaub in 1848-49, three cases occurred, with the same unfavour- 
abfe result. And, so far as I am aware, the case I have just 
detailed is the first successful |>rimary amputation at the hip-joint 
in Scotland. But the principal interest which such a case possesses, 
seems to me to be the consiaeration of those circumstances or con- 
ditions which may have conduced to the successful result, and 
which may. influence our practice in similar cases. 

The age of the patient may seem to explain the favourable result. 
It has been said that in young patients, from the greater remedial 
powers of nature, and the smaller surface caused by the operation 
in them, the operation is likely to be more successful; but this 
is very questionable. The remedial powers in young persons are no 
doubt great, when once a certain point has been passed ; but the first 
effects of shock either from accident or operation, and especially the 
loss of blood, are not well borne by such patients, and these^ together 
with the irritability of constitution, which is often marked, in a great 
measure, I think, counterbalance the remedial powers observ^ in 
them. Then^ as to the less amount of cut surface, though less 
absolutely, it is quite as great comparativeljr to the size and vital 

Sowers of the patient. Tne amount of mutilation, the consequent 
eran^ment of the circulation, and all the risks depending on these 
conditions, are at least as ^eat relatively in the boy as in the 
adult. From what I have observed in the case of primary amputa- 
tions in young children, the patients sometimes sink rapidly and 
without any very apparent cause, whilst even the successful cases 
are often atten^d at first with as urgent constitutional disturbance 
as in adults. Indeed, the state of the patient whose case I have 
recorded, shows how great was the constitutional shock during the 
first four daj^. and how slowly full reaction set in. The true causes 
of success will, I think, be found in the nature of the injury, the 
small amount of blood lost, and the comparatively little shock he 
was subjected to after the occurrence of the accident. 

1^^, As to the character of the injury. Although so excessively 



1964.] SUROiCAL CASES BT MR SPENCB. 5 

severe as to necessitate amputation, and though in dangerous 
pioximi^ to the trunk, the destructive force was limited to the parts 
over which the wheels had passed, — there was no laceration ot the 
limb below, nor of the abdominal region above, and there was little 
bleeding from the contused wound. Then the boy was seen imme- 
diately, the limb adjusted, and he was conveyed at once to his own 
home, so that he scarcely suffered any secondary shock from removal. 
Now, let me contrast these conditions with those of another case 
occurring in my hospital practice, and some of the causes which 
greatly determine the results will be pretty apparent. A man was 
admitted under my care in consequence of an injury inflicted by the 
explosion of a large iron flask containing gunpowder. The flask, 
the metal of which was about a quarter of an inch thick, had been 
in close contact with his body when it exploded, and the wound 
was therefore similar to that caused by the bursting of a shell. 
The thigh was almost separated from the trunk at the upper and 
inner part. ^ The pectinsBus, adductors, and the hamstring muscles, 
at their origins from the tuber ischii, were divided and torn into 
shreds, whilst the front of the abdomen and lower part of the thorax 
were severely scorched by the explosion. The femoral artery, 
largely exposed, had escaped injury, but the vein seemed twisted ana 
injured, as the blood was coagulated in it. There had been consider- 
able bleeding from the arterial branches divided, and slow oozing into 
the textures of the limb was going on when the patient was brought 
into the hospital. The accident had occurred m Lanarkshire, and 
the patient had to be conveyed partly by road, and then by railway 
to Edinburgh. In this case also, the only chance of life and relief 
from suffering was removal of the limb at the hip ; but after rallying 
during the first twenty-four hours, he died on the third day. Here, 
in contrast to the case of the boy, we see the disadvantages of a 
long and tedious journey, and renewal of shock from time to time, 
from the unavoidable movements in being so conveyed to town ; 
the slow loss of blood from oozing into the tissues of the limb ; 
the extent and severity of the wound, and the scorching of the 
abdomen and chest, an injury very dangerous in itself; — such 
circumstances are sufficient, I thiiik, to explain the fatal result, — 
and from what I have observed in cases of primary amputations, these 
are conditions which, according as they are present in greater or 
less degree, most materially influence the success of such operations. 
Perhaps it may seem that I do not sufficiently appreciate the im- 
portance of the patient enjoying the benefits of pure country air, 
instead of that of a hospital ward. But whilst it is perfectly true 
that there is much need of doing all we can to improve the ventila- 
tion of our hospitals, the dwellings of the working-classes in the 
country aire not always or even generally models of ventilation. In 
the case of the boy. the room he occupied was a small closet, low 
in the ceiling, just large enough to contain a small fixed bedstead, 
leaving barely room to pass between the bed and the wall, — ^its only 



6 SURGICAL CASES BY MB SPENCE. [JULT 

means of ventilation a small window and the door opening into the 
common room of the family, which also contained beds, so that what- 
ever the purity of air in the country round, he did not enjoy much 
of it. Without denying the bad effects of vitiated air in hospital 
wards, and the necessity of doing all we can to remove that cause 
of mischief, I cannot help saying that a good deal of nonsense is 
spoken and written about the dangers of operations in hospitals as 
compared with those in private practice, as if all depended on nospital 
air alone. From some of the discussions of the subject by corre- 
spondents in the weekly medical journals, and from recent proposed 
methods of ascertaining the results of surgical operations in hospitals, 
it would almost seem as if some statisticians had so crammed their 
brains with mere figures as to have no room left for a single idea, 
or even so small a glimmering of common sense as to make allow- 
ance for the nature and class of cases admitted into great hospitals, 
or to pay the least attention to the circumstances under which the 
patients are when admitted, to say nothine of the surgical treatment. 
As to the operation itself, the difficulties were on^r such as must 
always more or less present themselves in operatinff in cases of injury, 
where the lacerated textures prevent us from obtaining regular naps, 
and where the comminution of the bone deprives the operator of the 
power of leverage to facilitate disarticulation. There was, however, 
comparatively little difficulty here, although the fragment I had to 
grasp was small, because I had taken care to pass the knife deeply 
so as to open the front of the joint in cutting the anterior flap, and 
by doing so the difficulty of disarticulating is much diminished. 
There was, however, a condition present which I have seen cause 
serious diffictdty in amputation of the thigh for compound com- 
minuted fractures, when transfixion was attempted, 1 mean the 
dragging up of the lower part of the femur, by the hamstring and 
adductor muscles, and the projection of the trochanteric or upper part 
by the psoas and iliacus flexing it on the pelvis, so as to project it 
towards the skin, and prevent the knife being carried down in cutting 
outwards. In this case it was of no consequence, because the soft 

Earts in front were so injured that I could not get a long anterior flap ; 
ut, supposing the tissues to have been sufficiently sound, the bone 
was so tilted forward that I could not have carried the knife onwards. 
In such cases I would strongly recommend cutting the flap of integu- 
ment and fascia from without, and then transfixing across the joint, 
or to cut the flap altogether from without inwards as is now generally 
done in primary amputations of the limbs. In regard to the vessels, 
it will be observed that in this as in the former successful case of 
hip-joint amputation which I communicated to this Society, I put 
a ligature on the femoral vein as well as on the artery. In my 
former case I did so with great dread of the result, but I have since 
done it in some cases of amputation, and as they all did well, I 
am sometimes inclined to think that, instead of being hurtftil as I 
used to dread, it may possibly be useful as preventing imbibition 



1864.] SURQICAL CASES BY MR 8PENCE* 7 

or absorption of pamlent or sanions matter from a large woanded 
surface ; but I confess I have still so much of lingering prejudice 
that I do not like to try or urge the practice generally. I have, 
however, no hesitation now in applying a ligature when venous 
bleeding is troublesome after amputation. 

In regard to the temporary arrestment of haemorrhage during the 
operation, that was most efficiently performed by the manual com- 
pression of the external iliac on tne brim of the pelvis, and by an 
assistant grasping the posterior flap at its base as soon as it was cut, 
and pressmg a large sponge firmly on its surface, so that the whole 
amount of blood lost certainly did not amount to five ounces. I 
believe I was the first to use Lister's abdominal compressor in a 
case of amputation at the hip-joint, and then with perfect success, 
and I have since applied it several times with advantage in amputa- 
tions through or near the trochanters^ but I have also noticed that it 
requires great care to prevent it gettmg displaced during an opera- 
tion, and becoming inefficient. As to the present case, probably 
from the small size of the patient, or other cause, I found that 
whilst I could compress the abdominal aorta with the hand, I could 
not maintain thorough pressure with the tourniquet, and that the 
efforts at vomiting had a constant tendency to displace it, and I 
therefore could not trust to it during the operation. I cannot con- 
clude without expressing my acknowledgments to the gentlemen 
who assisted me at the operation, and especially to Dr Brown and 
Dr Smith, on whom the after treatment oi the case devolved, for the 
great care and skill thej^ bestowed upon the patient, and to which, 
under Providence, I believe his recovery is mainly due. 

2. Case op Spontaneous Gangrene op the Lower Extremity, 

ACCOMPANIED BT A RARE FORM OP ARTERIAL LeSION. 

Mrs Smith, aetat. 79, was admitted into the Eoyal Infirmary 
under my care, on the 18th of September 1863, suffering from 
spontaneous gangrene of the left leg and foot. The history of her 
case, given me by her medical attendant Dr Wilson, was the fol- 
lowing : — 

" I first saw Mrs S. on the 13th of August last. I found her in 
bed, complaining of severe pain in the leg and foot, which pre- 
vented her sleeping at night, and this she stated had begun some 
time previously. There was at this time no change in the appear- 
ance of the limb, and I did not then examine the state of its 
circulation. Her pulse at the wrist was rather frequent and feeble. 
She had been appljing turpentine as an embrocation to the limb, 
which I advised lier to discontinue. I prescribed opium pills, to 
allay pain and procure rest The following day, wnen I visited 
her. I was informed that the pain had ceased, but that the limb was 
cola. On examination this proved to be the case, and no pulsation 
could be felt in any of the arteries of the leg. I carefully examined 
the state of the heart, but no abnormal murmur could l>e detected ; 



8 SURGICAL CASES BT MR BPEKCE. [JULT 

but her lips and face were rather blue. The limb was wrapped in 
wadding, opiates dven to procure rest, and the patient's general 
strength supported. Gradually the limb became discoloured and 
shrivelled, and ultimately a line of demarcation formed below the 
knee. Under these circumstances, as the foetor was intense, and her 
general health not very much sunk, whilst the line of demarcation 
seemed tolerably decided, she was sent to the Royal Infirmary, in 
the hope that amputation might probably be attempted." 

On admission into hospital, I found her exhausted, and she had 
an anxious expression ; her tongue was furred, and rather dry in 
the centre ; the pulse was slow and felt firm, but this was evidently 
due to the atheromatous state of the arteries. The leg, though dry 
and shrivelled at the foot, had apparently died more rapidly above, 
as it presented more of the appearance of humid gangrene. Im- 
mediately below the knee there was a deep line of demarcation 
around the limb, presenting a tolerably healthy OTanulating surface, 
covered with laudable pus. No pulsation could be felt, however, 
either in the femoral or external iliac arteries of that side, and I 
observed some slight mottling of the lower part of the thigh as if 
from superficial venous congestion, to which I drew attention, that 
any increase of it might be watched. At my next visit I found 
that the patient had suffered from nausea, and was very restless ; 
there was heat of skin over the trunk and arms ; and the pulse was 
more frequent and irregular. Her face, though flushed in the 
cheeks, had a more sunken appearance, and the tongue was dry. 
She was suffering from an accession of irritative fever. The thigh 
of the affected limb felt colder ; the mottling from vascular conges- 
tion was much more marked; whilst the line of demarcation had 
an unhealthy, sloughy look, with purple edges. It was now quite 
evident that the gangrene was extending, and that little could be 
done beyond allaymg nain, and relieving the patient from the foetor 
by applying Condy's nuid and charcoal. The symptoms gradually 
became worse, and the patient died on the fourtn day after her 
admission into hospital. 

Leave having been obtained to examine the body, the arterial 
system generally was found to be affected with atheromatous and 
earthy degeneration. The vessels of the lower extremities, and the 
iliacs and lower part of the abdominal aorta were carefally dissected 
out, and reserved for further examination. When this was done 
the conditions observable in the preparation now before the Society 
presented themselves. The vessels of the leg and thigh affected by 
atheromatous disease were found plugged by coagula, as is generally 
seen in such cases ; but in the left iliac artery, just at the point of 
bifurcation into external and internal, was seen a condition very 
rarely met with. At one part its internal and middle coats seemed 
to have given way, and the blood had forced itself between them 
and the external coat, so as to dissect or separate the tissues for 
some distance, coagulating between them, and throwing inwards 



I i - 



■ f 

\( 



M»« .OPKN'.'K'.- 'A.SK '/ Am-i 



^'\ 



s 



18e4.] SUBGICAL CASES BT MR SPEKCE. 9 

the inner coats, so as to arrest the drcnlation at the affected part ; 
and, what is still more nnnsoal, the dissection of the coats was in 
the opposite duection to the natural current of the blood* 

Bemarka. — ^This form of arterial lesion — dissecting aneurism — is 
occasionally, though not very firequentlyi met with in the aorta, 
but is of extremely rare occurrence in vessels such as the iliacs. 
Indeed I am not aware of any preparation showing such a lesion in 
any vessel smaller than the aorta, and in all the cases I have seen, 
the separation of the coats has been in the direction of the cir- 
culation; but in this preparation the separation is towards the 
heart; and I think this fact, taken in connexion with the history 
of the progress of the disease, will serve to determine what parts 
of the morbid appearance stand in relation to the gangrene as 
cause or e£kct. Looking at such a very evident source of obstruc- 
tion as the peculiar lesion presents, we are apt to conclude that it 
was the originating cause of the gangrene. But viewing the mor- 
bid appearances, and especially the direction of the sangmneous dis- 
section of the coats, in connexion with the progressive symptoms 
of the case, I think it much more probable tlutt the onginating 
cause was the more common one of coagulation occurring in 
atheromatous arteries, and that the lesion of the iliac prolmbly 
coincided with the period of the exacerbation of irritative fever 
and excited circulation ; that the current of the excited circulation 
being obstructed beyond by the previous cessation, caused the 
coats of the distended artery to peld at the diseased part, and the 
reflux current of the blood to force itself between the tissues of the 
artery, thus separating them in the backward direction towards the 
heart. If this view be correct, as I believe it to be, then the pre- 
paration before the Society has a significance beyond its rarity as a 
pathological specimen ; for it will point out a source of danfi^er in 
reference to Brasdor's method of operating for aneurism, whidi has 
not been adverted to. Hitherto our great dread, in regard to that 
method has been the risk of the runture of the sac when the vessel 
was tied on its distal side, though that has never yet happened ; but 
it is clear that the ligature in such a case would act lixe the spon- 
taneous distal obstruction in the case recorded, and a similar lesion 
of the artery and a dissecting aneurism might follow. 

In conclusion, the case points out the propriety of avoiding 
amputation in cases of spontaneous gangrene, if not absolutely, at 
least till the line of demarcation has not only almost but altogetner 
separated the dead from the living parts down to the bones, and 
until the vitality of the limb higher up is secure, as shown by the 
vigour of its circulation. In cases of chronic gangrene, resulting 
from cold, or after fever, such a line of demarcation as was present 
here would have been a perfectly sufficient warrant to operate ; but 
the conditions in cases ot spontaneous gangrene, arismg from inde- 
finite and probably persistent constitutional causes are very different. 

VOL. X.— NO. I. B 



10 DR VEALB ON SYPHILIS AND ITS TREATMENT. [JULT 

Article II. — Remarks on Syphilis and its Treatment. By Henry 
Veale, M.D., Assistant-Surgeon, Royal Artillery. 

In the fherapentics of Syphilis, the three following rules may be 
regarded as absolute, !««, That every non-indurated chancre should 
be thoroughly cauterized if the ulceration be progressive or sta- 
tionary ; 2dj That the escharotic employed for the destruction of a 
venereal sore should never be of less strength than the faming 
nitric acid ; 3rf, That every suspicious excoriation should be treated 
as a chancre. It is very seldom that any diflSculty is experienced 
in obtaining the cicatrization of venereal sores when they are treated 
in this way. 

"It has never occurred to me to meet with a true serpiginous 
chancre in military life, nor have I ever knowi^ a soldier in whom it 
had existed. 

Sloughing sores — sloughing phagedsena — are more common, and 
are almost invariably associated with a bad habit of body of one 
kind or another, and, after cauterization, are best treated by the 
tartrate of iron, both locally and internally, as Ricord long ago 
pointed out. 

Buboes. — It is acknowledged to be useless to attempt the repres- 
sion of a specific bubo, and as it is impossible to foretell whether 
any given bubo accompanying a venereal sore will prove to be 
specifically infected or not, it would seem to be prudent never to 
attempt repression at all. The result of such preventive measures 
as are usually recommended, viz., leeches, blisters, low diet, anti- 
mony, and other similar antiphlogistics, appears to me to be as 
unfavourable both to the part and to the system as any that follows 
suppuration itself, even when they happen to be successful ; but 
when they fail, the strength of the system has been wasted to no 
purpose, and a bubo remains, slow in its progress towards recovery, 
and, by its exhausting discharge, often developing any lurking 
tubercular tendency. As soon as a patient with a primary sore 
begins to have jjain and swelling in the groin with other symptoms 
indicative of incipient bubo, it will generally be found that the best 
practice is to apply hot fomentations and poultices, to enjoin 
absolute rest of the part, at the same time to diminish in no respect 
our care for his general health, and, if pus forms, to make a small 
but dependent ojjening the moment its presence is detected. I am 
opposed to waiting until more complete suppuration shall have 
occurred, as well as to the practice of " free incision, and coidd 
easily adduce cases in support of what I deem to be the more 
suitable treatment ; but lallacies are too apt to lurk in such a 
method of proof, and I willingly fall back upon the following con- 
siderations, which, perhaps, will in themselves be found to be of 
sufficient weight. 

The main objects in treating a suppurating bubo are to cause it 



1864.] DR VEALE ON SYPHILIS AND ITS TREATMENT. 11 

to disappear as rapidlj as possible, and to leave the least perceptible 
trace of its existence. Now, such a bubo is an abscess, formed 
either in a gland or in the connective tissue immediately investing 
it, or in both of these structures, and the pus may be either simple 
or chancrous. Supposing, then, the pus to be simple and innocuous, 
it will be admittea tliat early evacuation by an opening dependent, 
and just large enough to admit of the pus escaping reaaily, will 
most conduce to rapid recovery with the least deformity. It must 
be remembered, however, that one cannot tell beforehand whether a 
given bubo in its early stage is simple or specific, or in which of 
the structures the pus has been formed; but, granting for tlie 
moment that specific buboes require a different treatment from the 
simple ones, the question arises, whether it is not advisable to give 
the patient the benefit of any doubt in the diagnosis, and in all 
cases to act on the most favourable presumption ? An answer in 
the affirmative will scarcely be denied. But if the bubo be 
specific, why should the opening be delayed or differently per- 
formed ? Because, it is said, it is desirable that the structure of 
the affected gland may be more completely disorganized, so that, 
eventually, wnen the skin gives way over it, the gland may be the 
more readily ejected as a siough. Let us observe with attention, 
however, the state of the parts when a spontaneous opening occurs, 
or when at length an incision is made in such a case, and we shall 
invariably find the skin undermined, and the connexions between 
the gland and the adjacent connective tissue destroyed by ulcera- 
tion everywhere except for a small space at its base. The skin 
and fascia overlying the gland are not only detached from it, but 
most frequently m a condition quite ready to slough. It is not the 
gland that will be found to have suffered by the delay in opening, 
so much as the skin and connective tissue. And the reason is 
clear ; the gland derives its vascular supply from its base, the only 
part by which it is still adherent to the body, but its vitality by 
reason of this condition exceeds that of the sxin and fascia, which 
receive no such direct supply. Accordingly, if the natural process 
is not interfered with, the last-named structures are always more or 
less destroyed, whilst the gland remains in what, by a strange 
interpretation of the facts, has been usually called an " indolent 
condition.'' Now, is it not clear that the ulceration and destruction 
of the parts surrounding the gland have been caused by the 
chancrous matter which has escaped from the gland and become 
infiltrated among them, instead of finding a ready exit from the 
body? Such a conclusion would seem scarcely to admit of a 
doubt. It is a fallacy, then, to suppose, that delay in opening a 
bubo favours disintegration of the affected gland, except in so far 
as it likewise favours still more the destruction of parts which it is 
highly desirable to preserve. 

With respect to the second object of treatment, viz., that of 
respecting the natural appearance of the groin, no one can have 



12 DR TEALE ON SYPHILIS AND ITS TREATMENT. [JULT 

had mttcli practice in venereal diseases without obserrin^ how 
exceedingly anxious his patients are npon this point, in all classes, 
and nearfy without exception ; and I, therefore, cannot help regard- 
ing every line of incision beyond what is required for letting out 
the pus. as quite inexcusable. Extensive incisions in this part do 
not neai without leaving marks, nor do they heal rapidly at all, as 
a general rule ; and for the latter reason alone they ought to be 
avoided if possible. For precisely similar reasons the plan so 
frequently recommended of cutting away the undermined skm, or of 
destroying it by means of powerful caustics, is equally to be con- 
demned, for we may be sure that our patients will never have a 
very nrateful remembrance of us if we have unnecessarily produced 
unsightly and indelible scars upon them. 

It may be concluded, then, that the moment pus is detected in a 
bubo it ought to be evacuated, and by a small mcision : the latter 
being advisable in all cases, first, for the sake of preserving appear- 
ances, and, secondly, for the limitation of the extent of surmce to be 
infected if the pus should prove of a chancrous quality. This point 
may always be determined in the course of a few davs by the ap- 
pearance of the opening. If it show a tendency to heal, we may 
DC sure that we have not to do with a chancrous bubo, but if it 
have a red, irritable, ulcerating aspect, or if its margins become 
ash-coloured and sloughy, the case is otherwise, and the part should 
be dressed with a strong solution of nitrate of silver, sulphate of 
copper, black wash, or some similar application. Injections of the 
same snould likewise be made into the interior of the bubo, and this 
treatment should be continued until the specific nature of the 
ulceration has been eradicated. 

But, unfortunateljr, patients frequently avoid applying for assist- 
ance until the mischiet has been done, and sometimes also we fail 
to detect the presence of pus early enough to enable us to follow 
this line of practice. In such cases, when we make the opening 
and introduce a probe, we fiind that it passes freely between the 
gland and the skin, showing that the subcutaneous tissue has 
already, so far, been destroy^, and the best practice then is to 
divide the skin by a single or a crucial incision, so as fully to 
expose the gland. The skin being then retracted and most care- 
fully preserved, the gland should at once be destroyed by the 
chloriae of zinc or some other equally powerful escharotic, whilst 
nitric acid should be applied to such of the surrounding parts as 
may have been infected ; and when the sloughs separate, and the 
part again puts on a healing appearance, the skin snould be drawn 
over it and union be promoted. It is really surprising, sometimes, 
to see with how little deformity a man may thus escape, even 
though the incisions at different times may have extended for 
several inches, and so many as three or four glands have been 
destroyed. It may, perhaps, be objected that sinuses are liable to 
follow upon small openings of the kind I have recommended, but. 



1864.] DB YEALB ON STPHILIS AND ITS TBBATMENT. 13 

without entering into an examination of the process by which 
sinuses are formed, which, however, wonld probably suffice to refute 
the objection, I may perhaps be permitted to lay some stress on the 
&ct. that I have never once observed a sinus in the groin to be so 
proauced. 

With reference to the general or constitutional treatment of 
venereal sores and buboes of the non-infecting kind, my belief is 
that measures of depletion are never required or even advisable. 
On the contrary, if the patient's health chance to be good, we should 
endeavour to keep it so : but if it be already in a bad state, it is 
almost needless to add that a tonic methoa of treatment is indis- 
pensable. 

I shall now proceed to the consideration of the indurated chancre, 
and of constitutional syphilis. 

Until an indurated chancre has been followed by enlargement of 
the lymphatics in the neighbourhood, I am of opinion that it is 
both justifiable and expedient to obtain the destruction of the part 
affected by it, for which purpose excision is especially applicable 
when the sore happens to be seated on any part which, like the 
prepuce, admits ot ablation without detriment or disfigurement to 
the patient. I make this statement with the utmost possible 
deference for those observers who affirm that it is useless to extirpate 
an indurated chancre. I do not pretend to deny that most frequentiy, 
when the induration has become manifest, the entrance of the poison 
into the system is inevitable, and has perhaps already taken place ; 
but I think it is an error to conclude that the induration is the result 
of the general contamination and a proof of it. For, if it were so, 
why should it occur only once? whv should we be unable to repro- 
duce it by a subsequent inocidation? why should not every super- 
ficial solution of continuity occurring at this period also undergo 
the same process? and why should it occur only at the site of 
inoculation? It would seem to be more probable that the specific 
induration is a strictly local process, dependent, it may be^ upon 
the conjunction of several conditions ; of which, however, the lollow- 
ing may be regarded as the chief: — First, tne constitution must 
have been previously free from syphilitic infection. It must not 
have undergone that kind of leucocytosis which the syphilitic virus 
produces. Indeed, every leuksemic state seems to be adverse to the 
process of induration : for we find that in women, in whom a chloro- 
ansmic or leukasmic state is more common than in men, the indura- 
tion of chancres is much less frequent ; and it is also observed that 
a chloro-ansemic state of the system, however produced, delays the 
specific induration even in men. Secondly, a certain degree of 
activity or concentration of the virus seems to be necessary j for, 
according to several observers, the induration produced by inocular 
tion through the medium of the blood, or with the fluid of certain 
secondary lesions, is not so well marked as that which results from 
the action of the virus implanted directly from a chancre. Thirdly, 



14 DB VEALE ON SYPHILIS AND ITS TREATMENT. [JULT 

certain purely local conditions seem to be favourable, although by- 
no means essential. Thus the process of induration is usually much 
more complete on the prepuce and on the lips, for example, than it 
is on the trunk, and it may perhaps be owing to a similar special 
aptitude or affinity that the lymphatic glands are so constantly and 
readily aflPected by it. 

It may perhaps be objected, however, that oftentimes when a 
chancre has been cauterized or excised, the wound, although made 
in parts previously unindurated, has been observed to undergo 
induration. But if this be a proof of the action of the virus through 
the medium of the blood, or of systemic infection, why is it that 
superficial solutions of continuity, happening simultaneously in other 
parts, do not also become indurated? Every day's experience 
shows that they do not, and yet the same blood and tlie same con- 
stitutional state exist for them as for the part that is undergoing 
induration. Why again, it may be asked, is a reproduction of 
induration in a wound made for excising a true chancre to be re- 
garded as a proof of constitutional infection more than the repro- 
auction of an epithelial cancer after imperfect extirpation ? The 
reproduction of the induration after excision much more probably 
proves that the quantity of tissue removed has not been sufficient ; 
It perhaps also proves that although the syphilitic virus may have 
passed into the blood, the true syphilitic diathesis has not yet been 
produced ; finally, it may prove the extremely gradual extension of 
the poison from tne primary centre or centres, and may serve as an 
argument not against the propagation of the poison through the 
medium of the blood, but in favour of a quite different explanation. 
If we withdraw our minds from the too exclusive contemplation of 
the part played in the animal body by the vessels and tneir con- 
tents, we shall perhaps be all the more ready to admit the possibility 
of the syphilitic poison extending itself from cell to cell, very mucn 
afl^r the manner of cancer. Indeed, in more than one respect, the 
analogy between cancer and syphilis is becoming every day more 
and more apparent. But, however, that may be, it will perhaps be 
allowed that the evidence in favour of the theory which attempts to 
account for the extension of the process of induration by reference 
to what is vaguely called systemic infection is not clear, whereas 
the view that the syphilitic virus disseminates itself through the 
contiguous cells, and is carried away by the lymphatics, in the same 
way as cancer, becomes more and more tenable the more we examine 
it Although, therefore, it is established by clinical observation 
that the specific induration of a sore only becomes perceptible to us, 
as a rule, after the poison has entered the system, there is nothing 
in the mere fact of induration which should cause us to regard the 
constitutional infection as either present or inevitable. Such indu- 
ration ought rather to be regarded as the direct result of the syphi- 
litic poison upon a part suited to undergo the process, and there is 
consequently no reason, theoretically, why the excision of a chancre 



I86i.] DR YEALE OK 8TPHILI8 AND ITS TBEATVEXT. 15 

ahoold not often be as successfal as the excision of its analogue — 
cancer; but in order to be so it most be oondacied on the same 
principles. It must obviously be a difficalt matter to aflford prac- 
tical proof of the truth of this conclusion, because, as yet, we cannot 
exactly determine the difference between a specific and an accidental 
induration, but it is at least safe for me to say that I have occasion* 
ally seen cases in which, after the extirpation of an apparently 
specifically indurated sore, there has been no evidence of systemic 
infection. But whatever may be the eventual verdict on this point, 
it is almost imiversally admitted that when the lymphatics have 
once become involved, the treatment of the sore alone is not suflicient. 
The poison having entered the system, it must be combated by 
constitutional remedies, and this at once opens up the question as 
to the use of mercury. 

The diversities of opinion which have prevailed concerning the 
properties of this drug constitute one of the greatest marvels in the 
nistory of medicine. Whilst a large number of medical practitioners 
have m successive ages continued to extol to the skies its remedial 
powers, others, equally conscientious, and sometimes conspicuous 
for their acute powers of observation, have as strenuously denied 
them. The question can hardly yet be looked upon as quite settled, 
considering that books are still being published in which precisely 
opposite opinions may be found concerning it. How can this be 
accounted for except on the supposition that certain minds are 
unconsciously swayed by preconceived opinions, and thereby become 
incapable of observing or interpreting aright the facts which pass 
before them ? ^^ Oculoa habent et mm videbuntj aures haberU et nan 
attdiebunt.^^ 

In the following case, on the correctness of the details of which I 
am able to place the most implicit reliance, mercury was found to 
exert a decidedly curative influence upon the syphilitic constitution, 
whilst several other remedies proved almost, if not absolutely inert. 

A. B. contracted a venereal sore, which appeared on the third 
day after infection, which was slow to heal, and became indurated 
somewhere about the fourteenth day, the induration being followed 
by enlargement of the inguinal and posterior cervical glands. In 
the fifth week a scaly eruption appeared on the skin, and there was 
slight soreness of the throat and swelling of the tonsils, but no 
idceration. 

From the sixth week to the end of the third month he took iodide 
of potassium in considerable doses, without any improvement being 
perceived. In the fourth month he took arsenic instead, and under- 
went a course of warm baths. Slight amelioration of skin affection 
ensued, but he became very weak and lost colour, his hair began to 
fall out, and, shortly afterwards, he suffered from severe ulceration 
of the tonsils. The arsenic was now suspended, nitrate of silver 
was applied to the ulcers, and mercury was given internally. Afl»r 
about ten days of this treatment the throat was well, and the 



16 DR VEALE ON SYPHILIS AND ITS TREATMENT. [JULT 

cataneonfl eruption Had almost disappeared. He now discontinned 
the mercoiyy because he found its action to interfere with his 
occupations. 

6^ Month, — Muscular rheumatism after exposure to cold^ 
relieved in three dajs by iodide of potassium. 

%th Month. — ^Fresh eruptions on the skin. Iodide of potassium 
internally. 

l\ih Month. — Skin affection as before; ulceration of tongue and 
throat. Iodide of potassium continued in large doses. 

12th Month. — ^The symptoms becoming more severe, and espe«> 
ciallv the ulceration of the mouth, the iodide of potassium was ois* 
contmued. Mercury was now given in small doses for nearly a 
monlhiy during whicn time the various symptoms disappeared, and 
the general health also improved. 

18th Month. — Health remaining good. A few brownish spots 
appeared on the pubis. No treatment. 

24:th Month. — ^Eruptions on the skin. Iodide of potassium, in- 
ternally, with iron. No improvement. 

26th Month. — Cutaneous symptoms as before; general health 
failing. The medicine was omitted. 

5l8t Month. — ^Ulceration of the throat having set in, he took 
mercury and iodide of potassium together, for a fortnight, when the 
throat got well, and the treatment was discontinued. 

34^ MontL — Cutaneous eruptions ; treated by iodide of potassium, 
without benefit. 

35th Month. — He took Donovan's solution for about a fortnight 
or three weeks, when the skin affection almost disappeared, and his 
health improved greatly. 

He continued well until the end of the fourth year, when he 
again became troubled with repeated ulceration of tne mouth and 
tongue. This was treated by the local application of nitrate of 
silver and the internal use of iodide of potassium. He suffered 
more or less in this way until the §9th month, having also crops of 

Eustules constantly coming and going, but never entirely leaving 
im. At various times he took quinine, acids, iron, sarsaparilla, 
and various other remedies, whilst the local use of nitrate of silver, 
chlorate of potash, borax, etc, was frequently had recourse to. His 
general health was sometimes good, more frequently indifferent, 
and oftentimes it was absolutelv bad. 

70th Month. — He suffered from unusually severe ulceration of 
the throat, mouth, lips, and marg^ of the anus, as well as from 
copious pustular eruption on the skin, for which he submitted to a 
month's mercurial course. This had the effect of freeing both the 
cutaneous and mucous surfaces from all the manifestations of 
syphilis, and his health also underwent a marked improvement. 
Wnen 1 last saw him, viz., at the end of the ninth year from the 
date of the primarv sore, he was still in good health, and had had 
no return oi syphilitic symptoms. 



1864.] DR VEALE ON SYPHILIS AND ITS TREATMENT. 17 

Notwithstanding that I have omitted, for brevity's sake, many 
important details connected with this case, it is yet sufficiently 
apparent that the symptoms throughout were those of the secondary 
stage, and that of the two systems of treatment — ^the mercurial and 
the non-mercurial — each had a tolerably fair trial ; the result being 
that iodine, arsenic, iron, warm baths, acids, etc.. proved absolutely 
useless as remedies of the syphilitic diathesis ; wnust a rapid disap* 
pearance of symptoms, and, in all probability, a diminution of intensity 
m the diathesis itself^ invariably followed the use of mercury. And 
the result of all that I have seen in military practice equally leads me 
to believe that mercury is the most potent of all remedies against the 
diathesis of syphilis in its secondary stage, as well as a^inst the 
lesions of the skin, mucous membranes, etc., b^ which it may be 
manifested. But notwithstanding that mercury is to be regarded as 
the most powerful controlling agent that we possess against secondary 
syphilis, it canndt be too strongly insisted upon that its use is not 
beneficial in every case, or in the same case at all times. The modus 
operandi of this drug is still only imperfectly understood. It seems, 
however, to be certain that all its preparations exercise, in a greater 
or less degree, a specific irritating action upon whatever parts of the 
animal economy they happen to reach. Consequently, its eflSacts 
may either be direct, indirect, or both. The skin protected by the 
epidermis is only capable of being irritated when the preparation 
applied to it is a soluble one, as the biniodide or the corrosive 
sublimate, or when, if insoluble, its action is promoted by fnction 
or prolonged contact. Still, when any effect is produced, it is 
invariably that of a special irritant The mucous membranes 
being of a more delicate structure are more easily acted upon ; and 
accordingly we find that the comparatively insoluble preparations 
are capable of irritating them to a considerable degree, whilst the 
more soluble ones corrode them, even in small quantities. Thus, five 
or ten grains of calomel, given internally, irritate the intestinal 
mucous membrane and produce purging, whereas a similar auantitv 
of the biniodide or corrosive sublimate would act as a corrosive irri- 
tant poison. When absorbed into the blood, its action remains the 
same except in degree. It then irritates every part with which it 
comes into contact. The mucous membranes, the secreting organs, 
the vascular tissues, the nervous matter, all experience its directly 
irritant action. But in irritating the Ivmphatic glandular system, 
taking this term in its most comprehensive sense, it alters the 
quality of the blood, diminishes its red globules, increasing the 
white, and rendering the fibrine less plastic. The blood being 
altered in this way, the nutrition of every part of the body must 
necessarily be mocUfied also. The secretions destined for re-absorp- 
tion must likewise be altered in quality ; and thus we arrive at a 
tolerably clear notion of what is to be understood by the indirect 
action of the drug. Whenever its action through the medium of 
the blood is at all prolonged, it is highly probable that the directly 

VOL. X. — NO. I. c 



18 DR VEALE ON SYPHILIS AND ITS TREATMENT. [JULT 

irritant effects are ^atly increased by the altered state of nntrition, 
— ^the result of its indirect action, and vice versd. The production 
of salivation, and the modified action of the liver, kidneys, and 
mucous membranes, as illustrated by altered bile, occasional albu- 
minuria, irritation of the urethra, cough, dyspnoea, and hsBmoptysis 
on the part of the lungs, and diarrhoea or haemorrhage from the 
intestines, are all examples of its directly irritant action, increased 
by its indirect effects. 

It is surprising what extremely minute quantities are capable of 
producing the specifically irritant action. I have often seen the 
twenty-fourth part of a grain of calomel given, every half hour, to 
produce ptyalism within twenty-four hours ; and although this mode 
of administering the drug is seldom had recourse to in this country, 
the experiment has been so frequently made as no longer to admit 
of a doubt that even smaller quantities may suffice for the develop- 
ment of its physiological effects, without there being any special 
susceptibility on the part of the patient. The quantity of the 
mineral existing in the blood at any given time during its admin- 
istration seems to be exceedingly minute, notwithstanding that its 
action upon the system may have been long-continued and pushed 
to excess. It does not matter in what doses, or by what^ channel, 
or for what length of time the drug is given, chemists can never 
detect any but the smallest quantities in the blood, and these not 
always. It is perhaps for this reason that some have even doubted 
whether it was absorbed at all or not ; but perhaps this circumstance 
should not be looked upon as being so very remarkable^ seeing that 
it may almost be regarded as a general law, that poisons of any 
kind, during life, can only exist in the blood in minute quantities 
and for short intervals. Whenever a poison has found its way 
into the blood, an effort is immediately made by the system to 
eliminate it, and so we find it excreted by the intestines, the kidneys, 
the lungs, tne skin, etc., according as there happens to be an affimty 
between the poison and one or more of these organs ; but some- 
times when these channels prove insufficient, the poison is excreted 
into the tissues in an insoluble form, as has been frequently observed 
in the case of mercury. It seems impossible, in short, for any 

Soison or for any foreign substance long to persist in the blood 
uring life. It is also to be noted that many poisons during their 
elimination irritate by their presence the narts which subserve this 
process. Iodine, for example, irritates tne kidneys, the urethra, 
and the commencement of the gastro-pulmonary mucous membrane ; 
arsenic irritates the mucous membranes and the skin, often causing 
eruptions on the latter. Copaiba irritates the mucous membranes, 
ana also frequently occasions eruptions on the skin, and so on. 
Such of the morbid poisons as may be supposed to have an irritant 
action likewise produce similar results. Small-pox, for instance, 
irritates the mucous surfaces and the skin, giving rise, on the latter 
especially, to its characteristic eruption ; and it is perfectly reason- 



1864.] DR VEALE ON STFHILIfl AND ITS TREATMENT. 19 

able to conclude that its specific virus is eliminated in this way. 
Bat it geneiallj happens that the greater the force with which a 
morbid poison ia eliminated the more actively contagions does it 
become, and vice versd. In the case of small-pox, the eliminative 
force is so intense, that even the insensible exhalations from the 
surface probably contain the poison ; and there is reason to believe 
that whenever, after the manifest action of a morbid poison upon 
the system, no specifically diseased state or diathesis remains, the 
whole of the moroid poison has been got rid of; whereas, when such 
a diathesis continues, the probability is that it is due to the persist- 
ence in the ecpnomy of the morbid poison which first gave rise to it. 

These considerations may perhaps facilitate a farther inquiry 
into the nature of syphilis. It may fairly be presumed that the 
sjrphilitic virus is a specifically irritant morbia poison, harmless 
when applied to the dense and resisting skin, but, even if not 
powerful enough to act upon the more delicate mucous membranes, 
capable of producing its special irritation on any part denuded of 
these protecting coverings. One sees the result of its direct and 
local action in the indurated sore, and enlarged and indurated state 
of the lymphatic glands which it produces. Absorbed into the 
blood, it especially irritates the skin and die mucous membranes of 
the mouth, throat, and anus, giving rise to various forms of erup- 
tion and ulceration, as well as to other modifications of nutrition ; 
but it is probable that the quantity so absorbed is extremely small, 
or else that it undergoes a change in quality, for if the virus were 
as active in the blood as it is at the site of the primary ulceration, 
inoculation by means of the blood should be as easy and as certain, 
whenever it contains the virus at all, as inoculation by the secretion 
of an indurated sore. It has been amply proved, however, that 
such is not the case. 

There is probably no part of the system which does not experi- 
ence the efiects of the irritation of the syphilitic virus ; but owing, 
perhaps, to the force of vital resistance being less in certain parts 
than m others, or perhaps by reason of the greater degree in which 
the skin and mucous membranes are exposed to variations of tem- 
perature and other sources of irritation, it is on them chiefly that its 
action shows itself. The lymphatic glandular system, however, is 
especially subject to the influence of the poison. Not only is there 
a direct absorption fi-om the primary sore to infect some of the 
lymphatic glanda, but it is probable that they may also be infected 
in a more circuitous manner, if there be any truth in the theory 
which regards them as organs which, besides contributing to the 
formation of the blood, constitute a series of filters, whose ofiice it 
is to collect from that fluid, and from the tissues generally, such 
foreign and injurious substances as may have found their way into 
them. At any rate, whether we accept this explanation or not, the 
fact is indubitable, that the lymphatic glandular system is especially 
susceptible to the influence of the sjq)hilitic poison, as is clearly 



20 DB YEALE ON STPHILIS AND ITS TREATMENT. [JULT 

shown bj the induration and enlargement of the inguinal, cervical, 
posterior aural, and mesenteric glands, which accompan;^ secondary 
syphilis. The proneness of the thymus to ulceration in cases of 
inherited syphilis, and the enlar^ment and ulceration of the tonsils 
in nearly all the sta^s of the disease, also point in the same direc- 
tion ; wnilst if any turther proof wese wanted of the irritant action 
of the virus upon the whole glandular system, it would be found in 
the diseases of the liver, kidbuey, spleen, testicle, etc., so frequently 
observed where its action has be^ of long duration, or favoured 
by £Eiulty hygienic or other unhealthy conditions. Lastly, the pro- 
duction of the state of chloro-ansemia, or the leucocytotic condition 
of the blood, so common in cases of constitutional syphilis, is 
more easily explained by admitting the irritant action of the syphi- 
litic virus upon the blood-elands than by any other hypothesis ; 
and clinical observation will, I think, justify the conclusions, — Ist, 
That induration and enlargement of the lymphatic glands is never 
absent when secondary symptoms are present ; 2dy That so long 
as their specific induration continues, it is an evidence of the per- 
sistence of the syphilitic diathesis ; and, Sd. That when the specific 
induration and enlargement of these glands disappear, the individual 
either entirely recovers or passes into a well-marked tertiary stage, 
in which one may presume that atrophy or degeneration of their 
structure has resmtCKl firom the long-contmued irritation. 

In entertaining the theory that the syphilitic virus is an irritant 
poison, it is also necessary to suppose that, as in the case of mercury, 
its efiects may be either direct or indirect, or both combined. The 
most evident of its direct efiects is induration ; and there is reason to 
believe, as I have already stated, that this varies in degree, not 
only with the previous state of the system and with the nature of 
the part, but likewise in proportion to the quality of the virus 
engaged in its production. It is quite consistent with the tendency 
of nearly all the most recent observations and reflections on this sub- 
ject, to suppose that the virus loses its intensity after a prolonged 
residence in the system ^ for it has been sufiiciently provea that the 
fluid products of the primary sore furnish a poison which is much 
more certainly and easily inoculable than that contained in the 
blood or in the secretions of a secondary lesion. It is also believed 
by some that the s^ptoms, both primary and secondary, which 
result from the action of this presumably modified virus are less 
severe than those which ensue upon inoculation from an ordinary 
and typical chancre. Still, whibt admitting the possibility of a 
change in the nature of the virus, it must not be forgotten that its 
indirect efiects, exerted through the lymphatic glandular system 
upon the constitution of the blood, and, consequently, upon the 
nutrition of every tissue and organ in the body, are probably more 
important. It will be admitted that the leucocytotic states produced 
by irritation of the lymphatic glands are not always the same in 
degree, and it is possible that they may not be the same in kind ; 



1864.] DB TEALE ON STPHILIS AND ITS TBEATMEMT. 21 

for there is oertablj a very vast difference between the complexions 
of cancer^ scrofiilai pregnancy, syphilis, mercurialismy etc. What 
the exact changes may ht which correspond with these yarioos states 
we are at present unable to determine^ but there is reason to believe 
that eveiy such condition necessarily involves a modification of the 
nutritive processes and a difference in the mode of reaction of the 
economy against the influence of whatever constitutes a stimulus. 
At any rate, whether this be true or not, the practical fact remains 
that the system becomes so modified by the action of the syphilitic 
virus that it soon loses the capability of undergoing the specific 
indurating process, no matter in what degree of activity or intensity 
thepoison may be employed. 

To resume, the primary induration appears to be the result of 
the direct action of the virus upon a part previously unaffected by 
it, either mediately or immediately ; the secondaiy lesion is probably 
a conseauence of the direct action of the poison upon a part already 
modified by its indirect effects ; the tertiaiy, on the other hand, is 
perhaps either a modification of nutrition caused by the prolonged 
duration of the indirect effects, or the result of the direct action of 
an altered virus, or, what is more probable still, a combination of 
these two conditions. 

The sequence of events in syphilis, then, would seem to be nearly 
the following : — 

Isty Induration of the part inoculated, equivalent to increase of 
virus by molecular or cell development. 

2d. Absorption and transmission of virus to the contiguous 
glands; induration and irritation of these organs; leucocytosis ; 
and, consequent thereon, modification of nutrition, owing to which 
the capability for induration diminishes, and for the most part 
ceases. 

3d. Passage of the virus into the blood*; its elimination through 
the skii^ and mucous membranes, and, consequently, eruptions and 
ulcerations. 

4thy Absorption by the lymphatics of the syphilitic virus not 
wholly eliminated ; irritation of other glands ; transmission of virus 
from one set to another ; further changes in the blood ; lesions of 
nutrition ; repeated passage of poison into the blood, followed by 
fresh eliminative efforts^ and so on. 

5thy Elimination failing ; alteration in quality of virus and its 
deposition in certain structures ; profound lesions of nutrition. 

Byphilis in fact seems to stand midway between smallpox and 
cancer, — the capacity for elimination of their respective morbid 
poisons constituting the main difference; and certainly, if we 
accept the proposition of Virchow, that ^^ every dyscrasia is depen- 
dent upon a permanent supply of noxious ingredients from certain 
sources," ana that the blood neither is nor can be its real seat, and 
then look to the fact that the lymphatic glands are the only structures 
which in secondary syphilis remain permanently indurated^ we are 



22 DS VEALE ON SYPHILIS AND ITS TREATMENT. [jULY 

almost forced to the conclusion that thej constitute '^ the local 
depots from which new quantities of noxious matter are continually 
bemg introduced into the blood." This theory is certainly more 
tenable than that which supposes the poison always to exist in the 
bloody and at certain perioos, viz., at tne outbreak of cutaneous or 
mucous manifestations, to undergo a kind of fermentation or zymosis; 
but it would occupy too much space to pursue it farther in this 
direction for the present. 

It has been seen that syphilis produces a leucocjtotic state of the 
blood, and that mercury has a similar effect, and it is very remark- 
able that the drug in certain cases diminishes and tends to extin- 
guish the leucocytotic nisus of the disease instead of increasing and 
perpetuating it. But it is equally strange that injections of nitrate 
of silver into the urethra will cure an inflammation already existing 
there, and yet give rise to it if the membrane be healthy. It may 
be said that the antisyphilitic action of mercury resolves itself into 
that of a special counter-irritant Still it is to be borne in mind 
that nothing more is to be understood by this phrase than is implied 
when we say that the salts of zinc, copper, silver, etc., are special 
counter-irritants when they subdue an inflammation of the mucous 
membrane of the eye or urethra. The counter-irritation established 
by mercury in a case of secondary syphilis is, however, probably 
more extensive, and consequently more direct than that produced 
by any other remedy; ana hence is to be explained, in part at 
least, its more lasting impression upon the disease. In a consider- 
able number of cases of secondary syphilis the enlargement of the 
lymphatic glands will be found to decrease under the use of mercury, 
to recur if the drug be prematurely discontinued, and then to be 
almost invariably fmlowea by lesions of the skin or mucous mem- 
branes. As to the form which the cutaneous eruptions may assume, 
it is probable that it depends far more upon the state of health of the 
sufferer than upon any aifference in the syphilitic virus. A roseola, 
for instance, will be connected with a comparatively good state of 
health, whilst rupia will be a tolerably certain indication of a bad 
one ; and this state of the constitution may either have been pro- 
duced by the syphilitic poison itself, or it may have preceded and 
been altogether independent of its action. The diagnosis of the 
particular kind of skin affection is therefore of some importance, as 
corroborating or guiding our opinion respecting the general consti- 
tutional condition of the patient — a point of the utmost importance 
with reference to treatment. 

This attempt to elucidate the modus operandi of mercury and of 
the syphilitic poison will perhaps be considered excusable if it be 
remembered that the uncertainty under which we labour, whenever 
we prescribe mercury for syphilis, convicts us of ignorance, both of 
the essential nature of the disease and of the modus operandi of the 
remedy. We know that sometimes, nay, often, mercury will act 
like a charm. It is not unusual to hear patients declare that it has 



1864.] DR VEALB ON 6YPHTLI8 AND ITB TREATMENT. 23 

made them strong, improved their appetite, and restored the desire 
for exertion ; whilst we see for ourselves that it has brought back 
the colour to their cheeks, and caused the eruption on the skin and 
mucous membranes to disappear. But we cannot as jet tell before- 
hand whether it will act m this manner in anj given case, or 
whether it will add to the Qvil effects of the disease ; and from this 
ignorance the practical rule is to be deduced, that mercury should 
he administered tentatively in whatever case of syphilis toe employ it 
Unless the health undergoes an improvement under its use, and 
unless the syphilitic manuestations £sappear, we mav be sure that 
it is doing no good, and may perhaps be doing mucn harm. We 
must not make an abstraction of the disease — sjphilis, and regard 
mercuiy as its antidote. Constitutional syphilis is a morbid state, 
the conditions of which, so far as we know them, are extremely 
variable, and it is only by patient, intelligent, and unbiassed ob- 
servation, that we can expect to attain to a knowledge of the par* 
ticular combination of them which admits of the curative action of 
mercury. 

The manner and form in which the drug is to be administered 
are also of importance^ and theonr and practice b(>th imite in 
establishing the second practical rule, viz., never to persist in any 
method which produces much local irritation. According to my 
experience^ the blue pill is the least irritating of the preparations of 
mercury which are given internally. The iodide is not only far 
inferior to it in this respect, but ukewise much more uncertain. 
There seems to be no foundation whatever for the opinion that the 
corrosive, sublimate or the biniodide is more suitable than blue 
pill in the advanced periods of the disease. When the mineral has 
once been absorbed into the blood its action is probably the same, 
whatever may have been the form und||jv^hich it was administered. 
The advantages of inunction and ftonigation seem chiefly to result 
from the little irritation caused by them ; but the disadvantage of 
inunction is, that it does not admit of our regulating the amount 
of the mercurial action. Fumigation, on the other hand, is incon* 
venient: it requires the use of apparatus, and in certain cases in 
private life is altogether impossible. Still, each method has some- 
thing to recommend it, and should certainly be had recourse to 
whenever it is thought necessary to submit the patient for a length- 
ened period to the action of the remedy. 

In the army it is not the custom to treat syphilis by a six months' 
mercurial course. The plan which is generaUy adopted, and which 
is probably the best under the circumstances, is to continue the 
mercurial treatment only until the disappearance of such lesions of 
the cutaneous or mucous surfaces as mav have existed. 

A great deal has been written and talked of late respecting 
the extent to which venereal diseases exist in the army, and the 
sickness and mortality which they cause, but it ought to be remem- 
bered that soldiers are taken into hospital for ailments which in 



24 DR YEALE ON SYPHILIS AND ITS TREATMENT, [JULT 

private life would never be allowed to interfere with a man's 
ordinary occupations. There can be no doubt that syphilis pro- 
duces a consiaerable per-centage of the inefficiency, ana, perhaps, 
of the mortality of our soldiers, and that it behoves us to endeavour 
to check it to the utmost of our power ; still, the statements which 
have recently been made concerning its ravages have led to 
exaggerated, erroneous, and most unjust conclusions. It is rarely 
that the soldier of the present day is reduced by syphilis to the 
cachectic and diseased condition which has been said to be so 
common in the army. Thanks to the intelligence and skill of their 
medical officers, the vast majority of our soldiers have, in recent 
times, been happily preserved from the evil effects of their venereal 
diseases. Fearml indeed would be the mortality and the pecuniary 
loss to die country, to put the matter on no higher ground, but for 
the solicitude with which an enlightened Government invariably 
provides that the treatment of our sick soldiers shall be intrusted 
to none but the competent I I do not pretend for a moment to 
assert that the treatment of syphilis, as practised in the army, has 
the effect of curing the disease entirely, and rendering the patient 
safe against relapses. Far from it. 3uch' a happy result seems to 
be only very seldom attainable under any kind oi treatment. The 
syphihtic disease has a truly wonderful power of persistence, and 
the doctrine which teaches that it may be left to itself on the cnance 
of its being worn out by time is surely a most pernicious one. I 
believe, however, that the plan of combating the syphilitic diathesis 
at those periods when it seems to be endowed with special activity, 
answers as well in the long run as if the mode of treatment by a 
six months' mercurial course were had recourse to. 

But it may be asked, what is the danger of leaving the disease to 
the effects of time ? In reply it is only necessary to say that constitu- 
tional syphilis impairs the health of every individual affected by it, 
and that, in its secondary stage at least, it is a communicable disease ; 
communicable from the parent to the offspring, and through this 
medium from the father to the mother; communicable also from 
the child to its nurse, and from the latter again to others, and so on. 
With reference also to this subject, I may recall a case in which 
syphilis, probably transmitted from the father, persisted unrecog- 
nised in nis son for thirty-two years. When 1 saw the latter he 
was suffering from languor, debility, bad appetite, dyspepsia, ansamia, 
nocturnal headache, sleeplessness, rheumatoid pains in the limbs, 
ulceration of the tongue, mucous patches of the throat, ulceration of 
the lips, nose, and anus, and a peculiar eruption on the hands and 
feet, consisting of indurated swellings, red, but painless, and vary- 
ing in size from that of a pea to that of a filbert. There was also 
slight enlargement of the glands at the back of the neck and behind 
the ears. This patient assured me that he had never contracted 
syphilis by any act of his own, that, in fact, he had never exposed 
himseU* to a chance of contagion, and the circumstances of the case 



1864.] DR TBALE OH 8TPHILI8 AND ITS TREATMENT. 25 

were Buch that I have no doubt he spoke the truth. Besides, there 
was no trace of any primary lesion, and the hereditary source of 
the disease seemed to be rendered still more probable by the fact 
that his health had always been indifierent, that some of his teeth 
were slightly notched, and that others were peg-shaped and prone 
to decay, that his brothers had always had unaccountably bad 
health, and, finally, that his father had suffered from syphilis in his 
youth. Now this patient had married early in lite, and had 
begotten children, and on examination signs of syphilis were found 
in them also. The eldest living, a^ed seven, had the two upper 
central incisors slightly notched, with enlargement of the tonsils 
and of the posterior cervical glands, squamous eruptions on the 
scalp, and a lean strumous habit of body. In a younger child the 
symptoms were still more decided, whilst the wife, at about the 
seventh year after marriage, suffered for the first time from cutaneous 
eruptions and ulcerations of the mouth and tongue. Surely, if the 
symptoms in either of these cases were due to syphilitic contamina* 
tion, it will hardly be contended that we are justified in leaving to 
itself a disease which runs on in this way from generation to gener* 
ation, imbittering, and probably shortening, the existence of each. 
And this is not a solitary case. Indeed, the more one sees of 
syphilis the more difficult will it be to avoid the conviction that, 
without specific treatment, the diathesis established by it persists 
indefinitely, and is capable of being transmitted hereditarily at a 
very much later period than is usually believed. The general 
opinion seems to be that inherited syphilis almost always shows 
itself within a very short period after birth. This may be true, 
but only on the supposition that the first symptoms are so slight 
that they fail to attract attention, and of such an equivocal kind as 
to require confirmation by subsequent and more decidedly syphi- 
litic phenomena. It is, perhaps, not easy to avoid falling into error 
whenever we try to determine what should be held to be evidence 
of syphilis under these circumstances, and what not. Still I think 
that enlargement of the lymphatic glands, without any other 
apparent cause, deserves to be regarded as the most certain ; but if 
with this sign there happen to be frequent eruptions on the body, 
on the scalp, behind the ears, at the angles ot the lips, or at the 
alsB of the nose, or onyxis, or ulceration of the mucous membrane of 
the mouth, the probability is that the disease is syphilitic. We 
ought, however, to be especially on our guard against accepting any 
one symptom as sufficient or conclusive. The notched or peggra 
condition of the teeth, for example, is a highly important symptom 
if found in conjtmction with others, but by itself it only indicates 
that certain conditions of the teeth and alveoli have existed, which 
m^ or may not have been caused by the syphilitic state. 

In many of the cases which have come under my observation the 
first explosion of manifestly syphilitic symptoms has been as late 
as the second year alter birth, and it is a curious fact tliat in many 

VOL. X. — ^NO. I. D 



26 DS YEALE ON SYPHILIS AND ITS TREATMENT. [JULY 

of these cases the lesions of the skin^ mncous membranes and glands^ 
notwithstanding their late manifestation^ are more easilY cored hj 
mercury than bj any other medicinal agent. If we looked merely 
to the element of time they would come under the category of 
tertiary symptoms, and should deriYe greater benefit from iodine 
and its compounds, but such is not the case. NcYcrtheless it must 
be admitted that wheneYcr mercury is to be employed for the treat- 
ment of late secondaij accidents, it recjuires to be given in extremely 
minute doses, and with such precaution as may efiectually prevent 
any excessive local irritation. The distinction between the second- 
ary and the tertiary stage of syphilis is, as Ricord long ago pointed 
out, a purely arbitrary one, and oftentimes the symptoms of the one 
will be mingled with those of the other ; still, experience has proved 
that when the bones are the parts affectea, when the cutaneous 
eruptions assume the tubercular form, when there is a tendency to 
the formation of tumours in the muscles and other parts, also when 
the fibrous structures appear to be involved, in these and many 
similar instances iodine is the sovereign remedy. There is one 
point, however, in connexion with the use both of this drug and of 
mercury which it is worth while to insist upon, viz., that their 
beneficial action seems to be promoted, and their possibly injurious 
effects diminished by the simultaneous administration of tonics, 
such as iron and quinine, and the adoption of as generous a diet 
and regimen as may be suitable to the patients constitution. 
Svphilis, it should never be forgotten, is one of the most debilitating 
of the dyscrasiae, and it may fairly oe questioned whether the iu 
effects which formerly attended the use of mercury were not in 
great measure due to the prolonged low diet and rigorous absti- 
nence firom tonics and stimulants which were then so constantly 
enjoined whenever this drug was given as a remedy for syphilis. 



Article in. — Observations on Shoulder PreseniaJtions of the Fcstus. 
Bj John Christie, M.D., F.R.C.S. Edin., Lecturer on Mid- 
wifeiy and the Diseases of W omen and Children, Aberdeen. 

Shoulder presentations are, in certain circumstances, amon^ the 
most dangerous occurrences which present themselves in midwifery. 
In a woman who has already borne children, in whom the pelvis 
is roomy, the membranes unruptured, and the os uteri dilated or 
dilatable, or where the membranes have only iust given way, and 
the uterus has not yet contracted firmly round the foetus, little or 
no difficulty is usually experienced in turning the child, and com- 
pleting its extraction in a brief space of time. But it is far other- 
wise when the pelvis is narrow, or the liquor amnii has been for a 
long time discharged, and the uterus has, consequently, come to be 
closely contracted around the body of the foetus, even when the os 



1864.] DR GHRUrriE OH SHOULDBB PRESENTATIONS. 27 

uteri is ftdlj dilated, or, if not so^ readily gives way to the dilating 
force of the operator s hand. 

But, setting aside the more common presentations of the shoulder^ 
and the consideration of the circnmstances which maj complicate 
them, and render their treatment difficult, I would direct attention 
to a class of cases which do not seem to have been much noticed bj 
obstetricians. This is possibly, of late years more especially, due 
to the simplicity aimea at in describing shoulder presentations. 
Madame La Chapelle and Nsgele were undoubtedly right in limit- 
ing malposition of the fdll-grown living foetus to arm and shoulder 
presentations. The latter, also. Judiciously divided these mal- 
positions, according to the order of their occurrence, into two. viz., 
iikQjirst position of the shoulder, in which the back of the loetus, 
compared with its anterior surface, is turned more than twice as 
often to the anterior wall of the abdomen of the mother ; and the 
secondj in which the same surface is turned towards the posterior 
wall.^ In either of these positions^ we are taught that the head 
lies towards the one or the other iliac fossa, and the bodv in an 
oblique direction over to the other side, the presenting shoulder 
forming the most depending part of the foetus, or that with which 
the examining finger necessanly first comes in contact. 

In the great majority of instances this is true, but there are cases 
in which the shoulder is the presenting part, and yet the body of 
the foetus does not lie in the transverse direction to anything like 
the degree almost universally assumed in regard to shoulder pre- 
sentations. Smellie, in this, as in so man^ other points of practice, 
seems to have been far more accurately informed than either his 
contemporaries or successors. In his " Sett of Anatomical Tables," 
etc (London, 1764), the thirty-second plate represents a shoulder 
presentation with the left arm prolapsed, and the uterus closely con- 
tracted around the body of the foetus. In this state of matters, the 
uterus, with its contained foetus, forms a roundish mass, having its 
greater diameter running from the right side somewhat obliquely 
up towards the left; and here we can, for the most part, move 
^^ the foetus with the hand, so as to turn the head ana shoulders 
to the upper part, and the breech and legs downwards." * 

But SmeUie shows, farther, that the shoulder may present, and 
the foetus nevertheless occupy a very different position in the uterus 
than that commonly ascribed to it. To understand this, let us see 
under what presentations nature is generally believed to be of 
herself able to efiect the expulsion of the foetus. Wherever, accord- 
ingly, the long axis of the foetus corresponds to the long axis of 
the uterus, no matter whether it be the vertex, the face, the breech, 
or the feet which presents, experience has ftilly proved that labour, 
as a rule, terminates without any interference on the side of art 

1 F. K. NaBgde, Lehrbuch der GeburtshtQfe, etc., Heidelb., 1844, p. 222. 
* W. Smellie : a Treatise on the Theory and Practice of Midwifery, vol. 1., 
4th edition, London, 1762, p. 334. 



28 DR CHBI8TIE ON SHOULDER PRESENTATIONS. [JULT 

With the view of removing obstacles to its due progress. True, Dr 
Churchill, with others, still ranges face and breech presentations 
under the head of ^'unnatural labours;" but when he tells us of 
the former, that ^^ of late years it has been established as a rule, 
that assistance is unnecessary merely on account of the mal- 
position," and of the latter, that ^^ the less interference the better 
for the patient," ^ we at once see his practice is far in advance of 
his Iodic Dr Murphy adopts the same arrangement of these pre- 
sentations, and is so influenced by it, that, in vie general case, after 
the labour has reached a certain stage, he recommends a very 
"meddlesome midwifery."* Dr Tyler Smith shies the question of 
arrangement, but agrees generally in the views expounded by Dr 
Murphy, and unmistakably, therefore^ leans to the idea that pelvic 
are preternatural presentations, requiring in the end, as a rule, 
rather active interference.' 

But, notwithstanding the views of these able and distinguished 
men, it is now-a-days, on almost all hands, virtually, if not formally, 
admitted, that the correspondence of the long axis, both of the 
uterus and foetus, is sufficient to constitute a natural position of the 
latter, whether it be its cranial or its pelvic end which is the pre- 
senting part ; and that, wherever this happens to be the case, labour 
is practicable by the unaided powers of nature. Accordingly, in 
the so-called cases of transverse presentations, it is the aim of art 
to bring about this correspondence by means ot certain manual pro- 
ceedings, and thus reduce the process of labour as near as possible 
to one 01 its natural types. 

But, even in the worst cases of transverse presentation, nature 
may herself overcome the obstacle to labour, as we see in the 
examples of spontaneous evolution and expulsion of the fcetus 
xecorded by Denman and Douglass, and in those of spontaneous 
rectification and turning, by other observers. In all cases of 
shoulder presentation, says Braun, in order to make labour possible, 
the foetus, whether mature or not, must undergo a change into the 
longitudinal position, or be subjected to dismemberment. These 
are effected m the following ways: — 1. By rectification of the 
foetal position; 2. By spontaneous turning; 3. By spontaneous 
evolution; 4. By the technical turning by the head, the breech, 
one or both feet, and one or both knees ; and, 5. By the decapita- 
tion of the foetus, or bv embryotomy, or its evisceration.* But neither 
of these modes incluae all that nature can do in bringing about a 
longitudinal position of the foetus in shoulder presentation. Another 
means of effecting this has been almost wholly overlooked. Smellie 

1 On the Theory and Practice of Midwifery, 4th edit., London, 1860, pp. 
412 and 421. 

' Lectures on the Principles and Practice of Midwifery, 2d edit., London. 
1862, p. 376, et seq. 

' A Manual of Obstetrics, London, 1858, p. 347, et seq. 

* Lehrbuch der Gebortshttlfe, etc. : Wien, 1857, p. 597. 



1864.] DR CHRiqriE ON 8H0ULDEB PRE8ENTATI0N& 29 

has^ Indeed, admirably figured the state of things (Tab. zzxiy.) 
which may lead, in a shoulder presentation, to the advance of the 
fcetns through the pelvis with its long axis in a longitudinal direc- 
tion, but he does not appear to have ever witnessed^ or to have even 
suspected such a thing to be possible. 

In speaking of the difficulties which may be encountered in pre- 
sentation of the shoulder, and in contrasting the round form ot the 
uterus, contracted close to the foetus in the usual state of things, 
with another state of the organ, in which it resembles ^^ a long 
sheath," with the child lying in it " lengthways " (vol. i. n. 334). 
the head being ^^ reflected over the pubes to the right shoulaer ana 
back, and the feet and breech stretched up to the Amdus " (Tab. 
xxxiv.), he describes a position of the foetus in which, as will pre- 
sently be shown, it may be extruded by the expelling powers alone, 
without anything resembling spontaneous evolution, or the other 
processes alluded to by Braun, taking place. For example, early 
in the morning of the 7th January 1861, 1 was called to Mrs A., 
16 Lon^ Acre, a primipara, who had been in labour from 5 o^clock 
A.M. of the preceding day. The os uteri was about two-thirds 
dilated, so that the presentation could readily be made out to be 
that ot the cranium in the first position. In a few minutes the 
membranes burst, and soon after a very small but male living child 
was bom. After separating it from die mother, when a vaginal ex- 
amination was made for the purpose of ascertaining the position of 
the placenta, the membranes of a second foetus were found project- 
ing through the os uteri, but the presentation could not be made 
out because of its heieht above the inlet of the pelvis. In half an 
hour, the pains, which had subsided on the birth of the first child, 
returned very actively, and on an examination being made the 
presentation was found to be a shoulder one, an arm having already 
come down into the vagina. At this moment the infant already 
bom, being very feeble, required my attention for a few minutes. 
During my absence from the bedside the membranes mptured, with 
the escape of a large quantity of liquor amnii. On now making an 
examination, the left arm was found to be that prolapsed into the 
vagina, the corresponding shoulder being at the brim of the pelvis. 
The nature of the case being now quite clear, I passed my right 
hand up along the arm till the trunk of the foetus was reached, and 
while cautiously but firmly endeavouring to get at the feet, for the 
purpose of turning, I found the head of the foetus to lie lorwards 
over the horizontal ramus of the left os pubis, while the neck was 
so bent that it lay in contact, at the same time, with the right 
shoulder. Moreover, the breech and feet were tumed upwards to 
the ftmdus uteri ; and the uterus contracted so closely and so power- 
ftilly round the body of the foetus, in the form of a " long sheath," 
whenever I attempted to force my hand onwards, that Icould not 
pass it so far up as to reach the feet, or even the flexure of a 
knee. Attributmg this in some measure to the rather awkward 



80 DR CHRISTIE ON SHOULDER PRESENTATIONS. [JULY 

position of my hand^^ I tried^ howeyer, before withdrawing it^ to 

Sush np the presenting part, with the view of brin^g the head 
own to the inlet of the pelvis ; but the very powerfin contractions, 
induced by every movement I made, rendered the attempt fruitless. 
Accordingly, I withdrew the ri^ht hand, for the purpose of substi- 
tuting the left, but on introducm? it into the vagina, I found the 
shoulder, neck, and head pushed down into the cavity of the pelvis, 
all compressed together, much in the form of the breech, and 
advancing so rapidly under the action of yerjr powerful pains, that 
I at once determined not to proceed farther in the attempt t was 
about to make to turn. In a few minutes the presenting parts 
came down to the perineum, and in half an hour swept over it, and 
passed through the outlet of the pelvis, with the shoulder jammed 
hard against the arch of the pubes, until the upper part of the 
trunk, with the head turned over towards the right shoulder, and, 
as it were, embedded in the neighbouring parts, was bom, when 
the rest of the body followed in the usual manner. The child was 
dead, and, considering it was a twin, large, since it weighed fully 
6 lbs. 

I made a note of the case at the time, and on consulting the 
authorities I had at hand, I found no similar one recorded except 
by Smellie, with a reference to, and copy of his plate in the excel- 
lent work of Dr Lee.^ And although, since the occurrence of 
this case. I have had several instances of shoulder presentation to 
deal witn, there was nothing in them to remind one of its 

Eeculiarities, untiL on the 22a September last, I was requested 
y my friend Dr Ferguson of the Cove, to see, in consultation with 
him, a case of transverse presentation, in a fisherwoman at the 
Downies, a fishing village on the Kincardineshire coast, and who 
was in labour with her second child. 

. On my arrival at the Downies, at 3 o'clock a.m.^ Dr Ferguson 
informed me that his patient had been in labour smce late in the 
afternoon of the previous day, and that on his arrival, about 8 
o'clock of the evenm^, he found the left shoulder, with the arm and 
navel cord prolapsed, presenting, the membranes having been 
ruptured some time before he reached the place. As the pains 
were not by any means severe or active, and the os uteri was sofb 
and well dilated, he proceeded at once to turn the foetus. In this, 
however, he was baffled; for although, in one or two attempts 
made with the right hand, he could reach one of the legs, he could 
not bring it down, in consequence of his hand becoming paralyzed 
under the action of the uterus, excited by every attempt to gain his 
object. In this position of the case he resolved to have a consulta- 
tion, and, as already, stated, I joined him about 3 o'clock of the 
morning in the management of it; and, on making a va^nal 
examination, I found the state of things exactly as represented by 

^ Lectures on the Theory and Practice of Midwifery, etc. : London, 1844, 
p. 339. 



1864.] DB CHRISTIE ON SHOULDER PRESENTATIONS. 31 

Dr FergOBon. The uterus, too, was still acting feebly in the 
absence of manual interference ; and but for the alarm natural to 
her in such circumstances, the patient was otherwise in a very 
favourable state for an attempt to turn being still made. Acting 
under this conviction, I accordmglj passed mj right hand up along 
the foetus, but by no justifiable torce could I reach the feet, or any 
part, indeed, by whicli turning could be effected. This was due 
m part to the close contraction of the uterus round the foetus in the 
form of " a long sheath," exactly as described by Smellie, in part 
to my hand bea>ming numbed under the strong contractions ot the 
uterus whenever an attempt was made to carry it up towards the 
fundus uteri, and in part to the palmar aspect of the hand not being 
readily turned towards the anterior surface of the foetus. For the 
latter reason I next tried the left hand, but, although it could be 
passed with much greater ease up through the inlet of the pelvis, 
and the position of the foetus could be far more readily ascertained, 
viz., that " the left shoulder, breast, and neck " were presenting, I 
did not consider myself justified in using such an amount of force 
as would have enabled me to reach a part by which the pelvic 
extremity of the child might be brought down, and so abandoned 
the attempt. 

On consulting farther with Dr Fer^on, I was inclined to 
recommend him to give a full dose of opium, and to wait for a few 
hours, when, chloroform having meantime been procured, a new 
attempt might be made to turn under its influence, and, in the 
event of that failing, recourse might be had to evisceration of the 
foetus, or even imm^iately to proceed to that operation rather than 
repeat the attempts already made to change its position. My friend, 
however, thought that one more attempt should be made to turn, 
and I advised him to try the lefl hand, since I had been able to 
use my own with so much more freedom than the right. Accord- 
ingly, he introduced the left hand, and after some time spent in 
cautiously but perseveringly forcing his way towards the lower 
extremities of tne foetus, he succeeded in hooking the forefinger 
into the flexure of a knee, which afterwards proved to be the ii^t. 
With great difficulty, in consequence of the cramped state of his 
hand, ne contrived to retain his hold, and while I assisted by 
external manipulation, ^e brought the knee so far down that at last 
he got a blunt hook passed over the ham. Being quite exhausted, 
or rather I should say, his left hand being quite benumbed, he 
passed the hook to me, when I proceeded to extract in the following 
manner, — Guarding with the forefinger of the left hand the end of 
the hook, which otherwise would have come in contact with the 
brim of the pelvis about two inches to the right of the symphysis 
pubis, I made traction with the right hand in the direction of the 
axis of the inlet of the pelvis, Dr Ferguson at the same time so 
manipulating the abdominal tumour externally as most efficiently 
to aid my effort to bring down the pelvic extremity of the foetus. 



82 DR CHRISTIE ON SHOULDER PRESElfTATIONS. [JULT 

In a short time this was so fax effected that the right foot passed 
through the vulva^ when a loop of tape was thrown round the 
ankle^ the blunt hook, of course, being removed whenever the les 
came down so as to permit of the escape of the foot. The lett 
hand being now set iree, I coiled the end of the tape encircling the 
ankle round the fingers, and. with the right hand introduced into 
the vagina^ pushed the shoulder upwards, while I at the same time 
made traction on the delivered leg, and tnus in a few minutes the 
version was ultimately effected. The body and shoulders of the 
foetus were next brought down, and after a brief delay, and with 
slight difficulty, the head was brought through the pelvis and 
delivered. The woman recovered without a bad symptom. 

What is remarkable in this and the preceding case is the longi- 
tudinal position of the foetus, and the corresponding elongation of 
the uterus in the form of "a long sheath." In the first case, 
nature clearly overcame the difficulty by compressing the head and 
upper part of the foetal trunk into a mass of such dimensions as 
permitted it to be forced through the pelvis in accordance with the 
mechanism which regulates the transmission through it of the foetus 
under ordinary cranial or breech presentations. This was, no 
doubt, greatly facilitated by the dilatation of the parts of the 
mother consequent on the birth of the first child. But although it 
shows how fertile nature is sometimes in overcoming apparently 
insuperable obstacles to labour, such a result is no more to be 
calculated upon than is spontaneous evolution, and such like, in the 
ordinary run of so-Killed transverse presentations. In the second 
case, the process had gone no farther than merely bending the head 
over into contact with the shoulder ; but had tne expulsive pains 
been at all effective, I have no doubt the upper part of the foetal 
trunk and the head would have been pressed together as in the first 
case, and that they would have come to present at the inlet of the 
pelvis condensed, so to speak, into one mass, even if they had 
never come to be so modellea or reduced in dimensions by com- 
pression as to become enga^d in or to pass through it. 

Of the propriety of tummg in either the one or the other case, 
there will, I presume, be no question, even although nature in the 
first stepped m so unexpectedly to the relief of the patient. To 
turn is out to do what she herself indicates, whether by rectifica- 
tion of the presentation, spontaneous evolution^ and so on, or by 
the process described in the first case, and that is, the substitution 
of a directly longitudinal for the transverse, or. to speak more 
correctly, oblique position which obtains in shoulder presentations. 
In these cases, as Foster well observed^ " considering the size of the 
foetus and pelvis in a natural view, it is just to hold cross presenta- 
tions absolutely impracticable by tne force of labour alone." ^ Still, 
it is of importance to understand how nature proceeds under the 
difficulties attending such cases, and to recognise, in the various 

^ The Principles and Practice of Midwifery, etc. London 1731, p. 195. 



18€i.] DR DATIDSON ON TUBEBGULAR LEPROSY IN MADAGASCAR. 33 

modes hj which she sometimes surmounts them^ a single under- 
lying principle which seems to direct her in effecting the birth of 
the toetus wnen it presents in labour, more or less transrersely, at 
the inlet of the pelvis. Her whole energies here seem to be directed 
to ultimately bring the foetus into a longitudinal position, and 
the obstetrician but imitates this when by art he brings either the 
cranial or the pelvic extremity of the foetus to take the place of the 
presenting part in a cross presentation. 



Article IV. — An Account of Tybercular Lqprosy in the Island of 
Madagascar. By Andrew Davidson, L.R.C.r. & S. Edin. 

{ConmunuxUed to the MeeHco-Ckirurgical Soddyj AprU 6, 1864.) 

Leprosy, which in Europe and America had become well nigh 
an historical disease, is again beginning to show itself in various 
localities in the old and new worlds. This fact will justify me in 
laying before the public a short account of the disease as I have 
observed it in the Islaud of Madagascar. The number of cases 
treated in the dispensaiy at Antananarivo during the year 1862 was 
nearly one hundred, and the following account of the disease is 
drawn up £rom the notes of the cases actually observed. 

For the sake of clearness of description, the progress of tubercular 
leprosy may be divided into three stages or periods, — the firsty 
characterized by the appearance of spots ; the second, by tubercles j 
and the thircf]^ oy ulceration or falling off of the members. These 
three stages may co-exist simultaneously in different parts of the 
body : thus, leprous spots may be seen on the trunk, tubercles on 
the face, and ulceration may be ^oing on at the extremities. Spots 
of changed skin, however, mvanably precede the tubercles, and the 
latter are in turn succeeded by ulceration. 

Tubercular leprosy is singularly uniform in its symptoms, progress, 
and termination in different parts of the world, nor has it suffered 
any modification whatever smce it was first described by Aretsaus, 
Severfd varieties indeed have been described by authors, as Lepra 
ancBsthesiaoa. Lepra tauricaj and some others ; but these varieties are 
not founded upon any differences of importance, but upon the 
degree in which a common symptom is present, which really 
furnishes no sufficient ground for establishing them as distinct 
varieties. 

The disease usually begins so insidiously that the patient is 
unable to state the precise period of its commencement. Some 
authors have described it as beginning with the constitutional 
symptoms proper to fever or inflammation, as hot skin, full pulse, 
ngors, and muscular pains. 

Judging from the many cases which have come imder my own 
observation, this must be a mistake. Fever may occur in a leprous 

VOL. X. — ^NO. I. B 



34 DRDAVIDSON ON TUBERCULAR LEPROSY IN MADAGASCAR. [JULY 

subject ; — it may eren be an exciting or, speaking more exactly, 
determining cause; but it must not on this account be supposed 
that the fever was the beginning of the leprosy, or that there was 
more than an accidental connexion between the two. Aretseus 
remarked justly, " the commencement of the disease gives no great 
indication of it ; neither does it appear as if any unusual ailment 
had come upon the man. ... In this way the patient's 
condition is hopeless, because the physician, from inattention and 
ignorance of the patient's ailment, does not apply his art to the 
commencement, when the disease is feeble." This could not have 
been said of leprosy, if it began with the symptoms of fever or 
inflammation. 

The patient probably discovers accidentally a small patch of 
his skin presenting a tint different from the rest of the body. Such 
spot may be seated anywhere, very frequently about the back or 
shoulders. The spot of changed skin may be of any shape, but is gen- 
erally oval or circular, and varies in size from sixpence to that of the 
palm of the hand. At first the change is so slight as to be observ- 
able only in some reflections of the light. The colour of these 
patches is almost exactly the same in every case, whatever the 
original colour of the patient's skin. In all, the first change is to 
a li^ht brassy tint, which, as the disease advances, becomes more 
distmct. It IS soon observed that the texture as well as the colour 
of the skin is affected. It becomes cracked, fissures running across 
the spots in all directions. The hairs upon the part become yellow 
and stunted, and afler a time fall off*, leaving the hair bulbs empty, 
patent, and enlarged. The affected skin acquires a greasy look, 
as if it were glazed or varnished, and ceases to be perspirable. 
From an early period the spots become thickened, but are not at 
first elevated above the surrounding healthy skin. This thickening 
depends upon effusion into the subcutaneous cellular tissue. As 
the disease advances the true skin becomes the seat of effusion, and 
is felt to be slightly elevated to the touch. 

In three or four of the cases which I have noted the disease 
seemed to be more particularly seated in the cutis vera^ elevating 
the skin into large, broad prominences. Sensation is at first 
heightened, slight wandering pains, formication or itching may be 
felt over the body or in tne affected parts only. After a few 
months this hyperesthesia gives place to ansesthesia ; thus it not 
nnfrequently happens that one or more of the older spots are 
decidedly numb and feelingless, while there is excited sensibility 
in the more recent ones. It has been already remarked that some 
describe, as a distinct variety, a Lqpra cffUBsmeeiaca^ but ansBSthesia 
is present more or less in every instance. In two cases this symptom 
was present in a very marked degree. In both the disease had been 
remarkably slow in its progress ; the tubercles dilatory in showing 
themselves. In neither had the malady reached the stage of 
suppuration, although the disease had existed in the one patient 



1864.] DR DAVIDSON ON TUBEBCULAR LEPROSY IN MADAGASCAR. 35 

for twenty, and in the other for twelve jears. I feel satisfied, firom 
carefol observation, that anaesthesia is more decided in the cnronic 
form of the disease in patients who live a sober, prudent life, 
whose habits seem calculated rather to mitigate than accelerate or 
intensify the malady. The hair, as I have stated, falls from the 
diseased spots ; but this is not confined to the spots alone, although 
it usuallv oegins there. The hair of the eyebrows never escapes, 
and I have noticed that it uniformly begins to fall from the 
outer angk inwards, I am not aware that this singular fact has 
ever been alluded to by writers on leprosy, although it is quite 
constant and sufficiently remarkable. The hair of the axilla and 
pubes, and the eyelashes fall as the disease advances, but the hair 
of the head is never affected. A popular writer on the East, in 
describing leprosy, has spoken of baldness as a symptom of the 
disease as observea in Syria.^ It may indeed happen that a leper, 
like any other man, may be bald, but it is an error to regard the 
baldness as a symptom of leprosy. This mistake is not uncommon, 
and arises from the writers having in their mind the description 
given by Moses of a perfectly different disease. Wherever the 
hair falls, the hair follicles become enlarged and patent, especially 
in the face, so as to present one of the most diagnostic signs of the 
malady. So characteristic is this of leprosy, either as a latent 
diathesis or a developKed disease, that I nave never seen a leper 
who did not present it ; — more, I have often been able from this 
condition of tne hair follicles alone to recognise members of a 
leprous family in whom the disease was yet latent 

The nakea eyebrows become thickened, rugous, and projecting, 
hanging over the hairless eyelids. To render the aspect still 
more unsightly, the eye assumes a lurid glare impossible to describe. 
Perhaps the word j&rrety is the most appropriate that can be 
applied to a change which no words can express. 

The second or tubercular stage of leprosy supervenes upon the 
first with various degrees of rapidity, sometimes within a few 
months, at others after the lapse of years, according to the intensity 
of the disease, the constitutional powers of the patient, and other 
circumstances to which I shall hereafter refer. The tubercles, 
usually of a duskv colour, smooth and distinct, be^n to show 
themselves on the iace. The lobes of the ears are thickened and 
irregular, and the whole external ear curved forwards toward the 
cheeks. The alse of the nose grow heavy, the nostrils dilating 
and the nose becoming flattened and studded with tubercles. The 
lips swell^ and are livid, the lower one more so than the upper ; and 
the chin is lengthened and misshapen ; the whole face bagged or 
puffy. The hands are livid as if from cold, the fingers swell, the 
arch of the foot becomes flattened by leprous efiusion beneath the 
fascia. In fact, tubercles may appear in any part of the body, 
although they are most common in the situations mentioned. But 
1 Thomson's *' The Land and the Book." New Edition. 



36 D& DAVIDSON ON TUBEBCULAR LEPB08T IN MADAQASGAIU [JULY 

thej are not confined to the skin alone, they afiect more or less the 
mucous surfaces. In the nose thej give rise to difficulty of breathing 
and oz88na, in the larynx and trachea to laboured respiration^ 
husky voice, and occasionally to aphonia. The lining membrane 
of the external ear is rarely affected. The cutaneous and pulmonary 
exhalations become foetid in the last degree. So peculiarly pene- 
trating indeed is the smell of leprosy, that there is no difficulty in 
detectmg, by the sense of smell aLonCi the presence of a leper in a 
large company. 

As these changes are going on, ulceration begins to take place, 
commencing generally on the hands or feet. These become livia 
*as if half frozen ; the temperature is really lower than that of health. 
The nails grow dry, shrivelled, and fall without pain. Tubercles 
burst in succession, discharge a thin watery matter, and after a 
time dry up. Other ulcers form on the fingers close to the joints, and 
deepen until the joints abeady infiltrated by leprous effiiion, their 
vitality all but extinguished, drop off. After the part falls away 
the ulcer heals over for a time ; thus, member after member dies as 
it were on the yet living body, leaving the sufferer as helpless to 
himself as he is loathsome to those who have to minister to his 
wants. 

So much for the outward signs of leprosy in its various stages. 
Its efkcta upon the ftmctions, vital and natural, are at first by no 
means so evident or uniform. The earlier stages of the disease 
may be accompanied by nothing abnormal in the ftmction of any 
of the organs. Experience alone informs us of the serious nature 
of the complaint, in some patients there is even from the begin- 
ning a remarkable torpidity, physical and mental, and this is 
observable in the later stages in eveiy case. The patient is unfitted 
for active work ; he is rarely irritable, but sluggish. The appetite 
is seldom impaired at the commencement, and even towards tne end 
it is rather perverted than lost The patient eats almost anything 
set before him, but without a relish. Loss of appetite is a most 
fatal symptom, and firequently indicates approacning dissolution. 
The tongue becomes large, .flabby, and foul, the gums bluish and 
roongy, and the bowels irregular or costive. Sooner or later in 
the malady indigestion manifests itself, the function of the liver 
being imperfectly or inactively performed. The urine, as regards 
quantity, specific gravity, constituents and their proportions, does 
not differ from the healthy standard. Menstruation in the female is 
seldom affected, for I found in twenty-two patients, between the ages 
of fifteen and forty, only one in which the menstruation was irregular. 

The ftmction of reproduction in the male and female continues 
unimpaired for a long series of years. The facts bearing upon this 
point were not recorded in many instances ; but I find that I have 
notes of nine persons in the second stage of leprosy and sick from 
three to six years, who had young children. This shows that 
even after the disease has existed several years, and advanced con- 



1661.] DB DAVIDSON OK TUBEBCULAB LKrB08T IX MAOAOAIK'AB* 37 

siderablj, the function of reproduction may not be mffectrd. It !«, 
however, eoually certain that it faiU during the ImX sta^e of the 
maladj. I believe that the ^Ubido xnexplthiltMj^ mentioned bj 
some authors, is a mere fancjr, — when the poictr ceaat'A, the d€»im 
is extinguished* 

Bespiration is impeded in two ways, — by thick^ninfr '^f the 
^ lar^^eal and tracheal mucous membranes from effusion, and from 
* a similar effosion into the substance of the lung itself and into the 
minute bronchL The pulmonaij capillaries lose their tone and 
become congested. The changes wiiich the blood under^iea in 
the lung are imperfectly carried on; the action of the heart Ijcromcs 
increasingly feeble with the progress of the disease ; the pulse is 
inyariably weak and slow. The fatal termination in Icprofty is 
often owing to some affection of the respiratory organs. 

In a few instances the blood was examined during the firHt and 
second stages of the disease. The coa^um was found occasionally 
to be loose : but the sensible qualities of the fluid were normaL 
It is probable that there is some materieB morbi in the blood, which 
may hereafter be detected, of which we are yet entirely ignorant. 

As bloodletting is eyiaently contra-indicated when tlie patient 
is reduced by the disease, the blood has seldom been examined 
during the last stage. 

Organic disease of the heart was not detected in any of the cases 
observed. Dr Copland mentions ^ case in which that oi^gan was 
found softened : further investigation is required to settle whether 
this is a coincidence or a result of leprosy. 

That the nervous systems, both organic and cerebro-spinal. are 
involved, is evident from what has already been said. The itching 
and flying pains, the heightened sensibility and succeeding anaesthe* 
sia, the depressed vital power, enfeebled action of the heart, inactive 
secretion, depraved appetite, — all evidence the extent to which the 
nervous system is implicated. These symptoms become more 
prominent as the disease advances. 

In conducting my inquiries, I had special regard to the causes, 
predisposing and exciting. Several points of great interest and im- 
portance were clearly and conclusively established, while others 
were left where I found them. 

Persons suffering from leprosy have a great reluctance to ac- 
knowledge an hereditary taint, in regard to a considerable number 
of the patients I was unable to gain any satisfactory information ; 
but I succeeded in tracing the disease in other members of the 
patients' &mily in the following cases: — 

TcAle showing the Hereditary Nature of Leprosy, 

FEMALES. 

Mamphantana, set. 45; ten years sick; father and sister leprous; several 

cmldren alive not leprous. 
RafitiiB, set. 40 ; mother and brother leprous. 



38 DB DAVIDSON ON TUBERCULAR LEPROSY IN MADAGASCAR. [JULT 

Bamananharivo, est. 42; mother and sbter leprous; married, no children; 

husband quite well. 
RanavOi set. 15 ; father and mother §aid to be healthy ; younger brother leprous. 
Ifara, est. 35 ; mother leprous. 

Ramatoa, set. 40 ; no account of parents ; two daughters, the youngest leprous. 
Raketaha, 8Bt. 25 ; fkther leprous. 

Izafy, set. 35 ; brother leprous. No information regarding father and mother. 
Renizoma, st. 46 ; three years sick ; younger daughter five years a leper. 
Isindra, set. 24 ; brother leprous ; father and mother said to be healthy. 
Laizoma, sot. 12 ; father, uncle, and brother leprous ; one brother well. 
Izala, 86t. 15 ; father and brother leprous. 
Rabako, st. 47 ; fifteen years sick ; brother and sister leprous. 
Rafozaehana, set. 40 ; fiither, mother, and one daughter leprous. 
Rasoa, est. 41 ; several of the family leprous. 
Ramavo, ast. 45 ; husband and child leprous. 

HALES. 

Samo, 8Bt. 12 ; father leprous. 
Bolo, about 11 ; mother leprous. 
. Ramanana, est. 36 ; mother leprous. 

Kotofotsy, ; one child leprous. 

Ramboamavo, ast. 55 ; mother, uther, and one child leprous. 

Andramanana, set. 35 ; mother leprous. 

Rabeampina ; brother and child leprous. 

Ratsilainga, set. 47 ; son leprous. 

Mangalahy, set. 10 ; several members of the family leprous. 

Manakavana ; sister and grandmother leprous ; father and mother healthy. 

Rafara, one daughter leprous ; no account of parents. 

Javy, set. 7 ; father leprous. 

Ibolo, father and mother both leprooi ; elder brother not leprous. 

These facts leave no room for doubt as to the hereditary nature 
of leprosy. It often happens that children who have been bom 
before the disease has manifested itself in their parents^ either 
escape the disease altogether, or at least much longer than the 
chilaren bom after the leprosy has developed itself in one or other 
of the parents. They also suffer from a milder and slower form of 
the malady. It is thus frequently noticed, and there are one or two 
instances of it in tlie above table, that the disease first attacks the 
younger children^ and then the others inversely according to their agcj 
— proving that the more advanced the disease is in the parents, 
the sooner will it affect the offspring. We also observe now and 
again the disease to break out in the children before it shows itself 
in the parent from whom they inherited it. Thus, in the table I 
have given, Benizoma, a patient aged 46, had suffered from leprosy 
for three years, while her daughter had actually been ill for five 
years. The disease thus appearing two years earlier in the child 
who inherited it, than in the mother who transmitted it. 

Leprosy will occasionally remain latent for at least one gen- 
eration, and re-appear in the next, — as in the case of J/ano- 
kavana^ whose own parents were healthy, but whose grandmother 
and sister were lepers. In all such instances, however, the leprous 
diathesis may be recognised in those who escape the ftiliy developed 
disease. 



1864.] DR DAVIDSON ON TUBERCULAR LEPROSY IN ITADAGASCAR. 89 

The signs of this diathesis are^ 1^, Falline of the hair of the 
cheeks^ and a patent condition of the hair follicles ; 2dj Loss of 
hair from the outer angle of the eyebrows ; 3d. Enlargement of 
the lobes of the ears ; 4thj Mental and nhjsical torpitude. The 
persons presenting these features often oie from diseases of the 
respiratory organs. 

Where a liability to the disease exists, exposure, overwork, grief, 

Soor or bad diet, cold and damp, imprudence and aebauchery, form 
etermining causes ; and when it has taken hold of the system, these 
circumstances powerfully tend to aggravate it. As men are more 
exposed to the operation of these causes than women, we may 
account for the fact that women are less liable to the disease than 
men ; and the well-to-do members of society than the poverty- 
stricKen ; while sobriety and care will tend to prevent its aevelop- 
ment or render its progress slower and milder. 

In a very considerable number of the patients, I could not 
obtain any reliable information respecting their family history. 
I several times found that patients altogether denied the exist- 
ence of leprosy in their families, althougn private inquiries «Aer- 
wards satisfied me that one or more of their relations were at the 
time suffering from the disease. It is looked upon as a disgrace, 
and few will admit that it is real leprosy from which they suffer. 
Then we all know how readily such circumstances as are thought 
to be discreditable are allowed to pass into oblivion. No trouble 
is taken to record the fact that an ancestor was a leper. Making 
allowances, then, for these considerations, I am inclined to believe 
that in the vaat majority — ^nay, in almost every case — careful inquiry 
would establish the existence of a hereditary taint. 

Yet there is no doubt a very small per-centage where no such 
taint can be discovered. In sixteen of tlie cases observed, the most 
careful examination and inotuiry failed to make out any history 
of leprosy in the patient's family. This leads to the important 
(question — Does leprosy originate de now at the present day, or is 
it spread by contagion ? We have in the hundrea recorded cases, 
three instances of husband and wife being both at once affected. 
There was one patient, too, in whom there was no history of leprosy 
in the family, but who had lived in the house with a leper. The 
question may be asked, are these coincidences, or are they something 
more ? At present we have not a sufficient number of facts to 
decide this question. It cannot be highly contagious in the 
ordinary sense of the word, for we constantly see husbands suffering 
from the disease living for years with their wives, without com- 
municating it, and vice versa. It certainly deserves notice, that 
while the Laws of Madagascar excluded leprous persons from society, 
the disease was kept within bounds ; but after this saJutary law 
was permitted to fall into disuse, leprosy has spread to an almost 
incredible extent There is no doubt that tnis result is partly 
owing to lepers being allowed to marry without any hindrance, but 



40 DR DAVIDSON ON TDBEBCDLAR LEPBOST IN MADAGASCAR. [jULY 

the natives are also stronghr impressed with the conviction that 
the disease is inoculable. Unon this point m^ cases cast no light. 
It is highljr probable that tne same originatmg causes, which at 
first gave rise to leprosj, are still in existence and endemic in cer* 
tain localities. It maj spring up now and then under certain 
circumstances, de novOy without contagion or hereditary taint. 
What the originating causes are is a profound mystery. In the 
island of Madagascar there are a number of different races — of all 
shades of colour, from the pure Negro to the Hovah, whose com- 
plexion is not darker than a native of Spain. These occupy widely 
varying climates. The central provinces, from their great elevation, 
possess a temperate climate, similar to that of the south of France. 
The climate of the plains, on the other hand, is tropical, and towards 
the north excessively warm. The circumstances and modes of life 
of these races are as varied as their origins, and the nature of the 
localities in which they reside. Yet leprosy affects all alike. The 
Hovah who lives in European fashion, and in a temperate climate, 
is no less exempt from this scourge than the African slave. It is 
found amongst the Betsemasarahas who eat pork, and amongst the 
Betanmenas who abhor it. It occurs where fish is an article of 
food ; but it is also to be seen where no fish is to be had, and where 
rice and vegetables satisfy the simple wants of the population. It 
exists in town and country, — at the elevation of 7000 feet above the 
level of the sea, along the coast line, and through all intermediate 
elevations. Kace, geographical situation, and diet, — all seem abso- 
lutely unimportant elements in relation to its presence or its spread. 
Probably the dirty habits so prevalent in many half- civilized 
nations must tend to aggravate it; eating from a common dish 
with the fingers ; the custom, very common in Madagascar, of inter- 
changing garments, and of all Ij^ing huddled promiscuously together 
at night, cannot fail to render it more inveterate, even if they do 
nothing in the way of originating it. 

It has been a favourite theory with many that leprosy is related 
to syphilis or to yaws. But what proof is there to substantiate 
this theory ? Syphilis has suffered marked modification in different 
ages and amongst different races. Leprosy has remained unchanged 
through seventy generations and longer, even in the same country. 
We do not see leprosy result from syphilis in England. The 
spread of syphilis in the fifteenth and sixteenth centuries was not 
followed by an increase of leprosy, but the reverse. 

Leprosy seems to be a disease sui generis distinct altogether from 
syphilis and yaws ; propagating itself by hereditary transmission 
and poeaibly by inoculation. It is probably seldom produced im- 
mediately and at once in any constitution from the causes originating 
it, but ^aduatty bj the persistence of the causes operating through 
successive generations. 

In the treatment of this most formidable disease we are still in 
the dark. Everything has been tried, and in vain. The utmost 



1864.] DR DATIDSON ON TUBERCULAR LEPROSY IK ITADAOASCAR. 41 

that can be accomplished in the present state' of our knowledge is 
to palliate, not care^ the disease. In a considerable number of the 
cases, iodide of potassium in various combinations, according to the 
peculiarities of tne case, was given, and often with marked effect in 
producing absorption of the tubercles, accompanied, however, bj 
loss of appetite and weakness in the patient. I will give two 
cases. 

Andriamanana, a blacksmith, seven jears unwell. The whole 
skin is altered in texture, thickened and glazed. The nose and 
lips thickened and tuberculated, the ears irregular and curved for- 
wards. The hair of the evebrows and eyelids fallen. Hands and 
feet livid, cold, and insensible. Voice rough and husk^, with pain 
in lairnx. Tnis patient was put upon iodide of potassium in com- 
bination with warm tonics. After a week's treatment some of the 
tubercles burst, others were being absorbed, and after a longer 
time the skin became much more natural, a few tubercles only 
remaining. 

Bavao, aet. 40. Two years leprous ; tubercles scattered over the 
epreater part of the body ; was ordered iodide of potassium in small 
doses three times a-day, with tepid bath, and generous diet. A 
manifest improvement took place, most of the tubercles having dis- 
appeared. The patient's appetite, however, began to fail, and after 
three months the iodide had to be suspended. In these, and in 
several other instances, the iodide of potassium really seemed to 
produce absorption, to cause the tubercles to disappear, and to render 
the skin thinner and softer. The patient Bavao was permanentlv 
improved, but in the case of Andriamanana, the weakness increased, 
ulceration of the cornea ensued, and death speedily took place. I 
cannot help thinking that the fatal result in this instance was 
hastened by the treatment. 

Arsenic, with attention to the general health, was perseveringly 
tried for months in eleven cases. The usual constitutional symp- 
toms of arsenic, when administered in medicinal doses, were mani- 
fested in several of the patients without any mitigation of the disease. 
I noticed, also, in more than one case, an inflammatory condition 
of the skin, especially in the face, to result. 

Where ulceration existed great temporary benefit was obtained 
firom the use of quassia in large^ frequently repeated, doses. I am 
indebted to Dr rowell, of Mauntius, for a knowledge of the value 
of this remedy in the ulceration of leprosy. Under its use ulcers 
heal for a time more readily than under any other treatment. 

When a venereal taint was known or susjpected, mercury was 
tried. The preparation used was the bichloride in small doses. 
No good was observed to result. 

A treatment directed to the improvement of the general health, 
and the due performance of the various ftmctions, with the use of 
tonics and occasionally of cholagogue purgatives, if the liver is 
inactive, will be of service. Should the ulceration be troublesome, 

VOL. X.— NO. I. p 



42 PR DAYID30N ON TUBERCULAR LEPROSY IN MADAGASCAR. [jULY 

quassia, alone or in suitable combinationSy will promote the healing 
process. Iodide of potassium given at intervals and in small doses, 
will help to promote the absorption of the effusion, care bein^ taken 
to suspend it if the appetite fail or the health suffer. The tepid bath 
will always be useful in promoting the action of the skin and the 
comfort of the patient Experience is also in favour of inunction as 
an adjunct to other treatment. It is probably more serviceable than 
any single remedy. The oil used by me was the best olive oil, and 
it was thoroughly rubbed into the skin twice a-day, after the patient 
came out of the warm bath. 

By the persevering use of ^ these simple means, many of the 
patients experienced benefit, although none were entirely cured. 
Yet, I am convinced that in the present state of our knowledge, 
more good may be hoped from such general treatment than from 
any single medicine used empirically. 

!Now that the attention of the profession has been directed to this 
disease, may we not hope that our knowledge of the therapeutics 
and pathology of this fearful scourge of our race may be speedily 
advanced. 



Article V. — Cose ^ Ccssarean Bection. mth Bwicestrful Bemlts to 
both Mother and Cnild. By Izett W. Anderson, M.D., King- 
ston, Jamaica. 

{Communicated to the Edinburgh Obstetrical SodOy, on 23d December 1863.) 

Ann BLACKWOOd, a black girl, was admitted into Lady Barkly's 
Lying-in Institution on the 25th of April 1863. As the nurse in 
attendance immediately detected something unusual, I was requested 
to see the case. 

On my arrival, I found her to be a strong healtliy-looking girl, 
apparently about twenty-five years of a^, and in active labour. 
On inquiring of her mother, who came with her, as to her previous 
histoiy, I ascertained that she had always been healthy, had never 
met with any accident, and had been about twenty hours in strong 
labour. On making an external examination, I was immediately 
struck with the very great narrowness of her pelvis. After the 

f)atient's recovery, I made careful measurements of the size of the 
alse pelvis, with the following results : — The anterior superior 
spinous processes of the ilium were at the same level, with only a 
distance between them of six and a quarter inches. From each 
of these points, round the back, measured fifteen inches. The 
mons veneris was unusually prominent, from the approximation 
and projection forwards of the horizontal rami of the pubes. It 
could be grasped by the fingers, applied laterally, ana proved a 
bony projection of at least an inch and a half in height, r rom the 
anterior superior spinous processes on either side of the centre of this 



1864.] DR ANDSK80N*S CASE OF CiESAREAN SECTION. 43 

projection measured three inches. On examination per vaginam, I 
found that only the two first fingers could be passed between the 
tuberosities of the ischium^ and even then they were in close ap- 
position^ and partially overlapping each other. The descending 
rami of the pubes were, however, much closer together, as only 
one finger could be passed up anteriorly between them, and even 
then with some difficulty. Posteriorly, between the ischial tuber- 
osities and the coccyx, two finders could only iust be introduced 
into the pelvic cavity. On passmg the finger as nigh up as possible 
into the pelvis, a small curved projecting sharp bony ridge could 
be felt on either side, but more developed on the left. The sacrum, 
as far as I could ascertain, was also more prominent than it shoula 
be. The os uteri could be felt with difficulty, and appeared dilated 
to about the size of a crown piece, though with regard to this I 
could not be certain. The presentation could not be made out. A 
good bag of waters projected into the vagina. No placental bruit 
or foetal heart sound could be made out. The vagina was cool and 
moist; skin natural; pulse 84, full and regular; tongue dry, 
brown, and furred (probably in consequence of a dose of Dover's 
powder, given some hours before I saw her) ; pains strong, regular, 
and bearing-down in character. 

I requested Drs Bowerbank and Fiddes to see the case with me, 
and after most careful and repeated examination, we all agreed that 
delivery bv any method " per vias naturalis " was impossible, and 
that the Gsesarean section was the only chance of escape for both 
mother and child. As we considered that the sooner it was performed 
the better, preparations were immediately made for the operation. 
Plenty of hot water was procured, with several new well-washed 
sponges. Chloroform, with the necessary instruments, were in 
readiness, and the trained nurses of the institution were at hand, to 
act as assistants if required. 

The patient was then placed upon the operating table, and 
chloroform administered by Dr Bowerbank. When complete 
anaesthesia was produced, this was handed over to one of the 
nurses to take charge of, leaving Dr B. at liberty to assist me. 
The catheter was then passed, and a small quantity jof urine drawn 
off: the rectum was ascertained to be empty. Standing on the 
rignt side of the patient, with a strong scalpel, I made an incision a 
little to the right of the umbilicus, about ten inches in length, ex- 
tending from a little above the umbilicus down to the pubes. I 
then at one point gradually deepened the incision, until the peri- 
toneum was reached, and cautiously opened. Introducing the two 
fore-fingers of the left hand, and usine them as a guard, I slit the 
peritoneum, both up and down, with a curved probe -pointed 
bistoury, to the same length as the superficial incision. Some of 
the intestines then escaped, but were easily returned and kept in 
9itu by the edges of the abdominal wound being closely applied to 
the uterine walls by Drs Bowerbank and Fiddes on either side. 



44 DR Anderson's case of cesarean section. [jult 

The nteroB, of a pale pink sbining appearance, with lar^e veins 
ramifyine on its surface, was thus iully exposed. An incision, 
cutting through about half the thickness of this or^n, was made, 
about six inches in length, exactly in its mesian hne. This was 
deepened at one point, and the uterine cavity opened. The waters, 
of a dirty-greenish colour, rapidly escaped, owing to the strong 
contractions of the uterus; and, notwithstanding all the care 
exercised, some ran into the abdominal cavity. Introducing the 
fingers of the left hand as a guard, with the probe-pointed bistoury 
I extended the wound both up and down^ to the extent of the 
superficial incision. Passing in the hand, I seized and extracted 
the presenting part, which turned out to be the left arm. The 
hand being again introduced, the feet were found, and the child 
extracted with care. The cord having been tied and divided, the 
child was handed over to the care of one of the nurses, who soon 
made it cry lustily. The uterus then contracted rapidly, and it 
was with a little difficulty that I passed in the hand, found the 
placenta adherent to the upper ana posterior part, picked it off, 
and removed it. During the delivery but slight haemorrhage took 
place, and that only fix)m the lips of the uterine wound. After the 
removal of the placenta, the uterus contracted rapidly and firmly 
to the size of a foetal head. Smart oozing took place for some 
minutes from some of the large venous sinuses at the lower edge of 
the uterine wound, but ceased on the application of a spon^ 
dipped in cold water. The abdominal cavity was then carefully 

Songed out with warm water, and a few coagula removed. The 
ges of the abdominal wound were approximated, and ten sutures 
of silver wire introduced, deeply, though not through the peritoneum. 
While this was being done, vomiting came on, repeatedly causing 
the escape of nearlv the whole of both large and small intestines, 
notwithstanding all our endeavours to prevent it. A little blood 
was brought up with the vomited matter. The line of incision 
was then dressed with a strip of dry lint, a thick pad placed on 
either side to make deep pressure, over this a broad roller, and 
finally the binder. The patient was then removed to bed, and ext. 
opii. gr.iij., in the form of pill, given as soon as the effects of the 
cnloroform had passed off. She presented no appearance of shock, 
skin being natural, and pulse 96, full and regular. 

9.16 P.M. Pretty well under the influence of opium. Lies quietly 
in bed, without making complaint, unless askea if she feels pain, 
when she complains of uneasiness in the abdomen, and says that she 
cannot breathe freely. Respiration, however, is normal. There 
has been no vomiting, though slight hiccough occasionally. Pulse 
is good, 112. A small amount of discharge has taken place ^^ per 
vaj^nam." Passed the catheter, and drew off about fviii. of clear 
urine. Gave directions to the nurse in attendance that the patient 
is to be disturbed as little as possible during the night ; no food is 
to be given, though small pieces of ice occasionally, if the thirst is 



1864.] DB ANDEBSON'B CASE OF CfiftAREAN SECTION.- 45 

great If pain is complained of, ext opii. gr.j. may be given every 
fliird hour. 

26th. — Patient slept well until four this morning, when, being 
restless, an opium pill was given, toeether with a little arrow- 
root, which she asked for. Soon after, she vomited a large 
quantity of watery bilious fluid. In the act of vomiting a large 
quantity of bloody serum escaped from the lower part of tne wound 
and through the vagina. She now complains of much pain in the 
lower part of the abdomen, paroxysmal in character, and due, I 
think, to uterine contractions. Only slight tenderness exists, on 
pressure being made. The facial expression is good; pulse 96, 
and regular ; tongue covered with a white fur, and inclined to dry- 
ness ; skin natural ; no nausea or hiccough ; says she feels very 
hungry. Passed catheter, and drew off about half a pint of clear 
urine. Ordered ice ad libitum^ and thin gruel for diet. Two grains 
of ext. opii. at once. 

27th. — Since last report patient has taken four grains of opium. 
She slept pretty well last night, though at times, the nurse says, 
she appeared very weak. The present state is — pulse 120, full and 
regular ; tongue moist, but furred in patches ; abdomen tvmpanitic 
and painful, though she bears well the pressure of the hand ; lochial 
discharge small in quantity, but free from foetor ; large amount of 
bloody serum is constantlv oozing from the lower part of the wound, 
soaking through the bandage and binder ; breasts flaccid and pain- 
less. Lies in bed with tne legs extended, and can move them 
freely, without increasing the abdominal pain. The expression of 
face is good; she is cheerful, and fond of talking. Ordered to 
continue the ice and thin gruel, and to take frequently the essence 
of beef in doses of a tablespoonful at a time. Ext. opii. gr.ij. 
statim. 

9 P.ir. Patient has had a bad day« The pulse has been high 
(above 130), with much heat of skin, and an increase of me 
abdominal pain and tympanitis. A poultice has been kept 
constantly applied to the abdomen, ana opium, to the extent 
of three grains, has been given in divided doses. She is now 
decidedly worse. The abdomen is enormously tympanitic, and 
very tender and painful, particularly in the region of the trans- 
verse colon. She has an anxious^ pinched expression of face, 
with cold sweat standing on the forehead. The skin is hot — 
pulse 144, and very weak — lochial discharge small in quantity — 
respiration very rapid — heart's apex can be seen pulsating much 
above its ordinary situation. I removed the dressings of the wound, 
and found that the greater part of it had united by the first inten- 
tion, while the remainder was in a healthy granulating condition. 
A large enema of warm water was given, and I tned to pass 
O'Bim's long rectum tube, with the intention of relieving the 
enormous ^mpanitis, but could not get it beyond the promontory 
of the sacrum. The catheter has been passed by the nurse regu- 



46 DR ANDEBSON'b case of CJESAREAN section. [JULY 

larly erery six hours since the operation, and the urinary secretion 
has always been free. Ordered a continuance of the hot poultices 
to the abdomen during the night, and one-grain pills of opium 
regularly every three hours, whether the patient sleeps or not. 
Beef-tea is to be frequently given, and hall an ounce of brandy 
every two hours. 

28th, 5.45 A.M. — Nurse reports that the patient was pretty quiet 
during the night, and took her, medicine, brandy, and beet- tea 
regularly. Occasionally, however, she seemed very low. This 
morning there is, I think, a little improvement. Her present state 
is — pulse 124, and a little stronger; features not so anxious or 
pinched; respiration not so rapid; cold perspiration replaced by 
warm ; abdomen less tympanitic and painful ; lochial discharge 
still small in quantity and toetid. Dressed the wound, which looks 
well, with lint dipped in warm water, and over that applied 
terebinthinate fomentations to the whole surface of the abdomen. 
Continue opium, brandy, and beef-tea. 

10 A.M. — Fully under the influence of opium, having taken five 
grains of the extract since nine last night. Can be roused, though, 
if left alone, sinks into a semi-comatose state, pupils contracted. 
Bowels have not been open since operation, and abdomen is still 
very much distended. Omit opium. Ordered an enema of a pint 
of gruel, with tinct. assafoetidae et ol. terebinthinae aa i&a. 

Evening. — Has just passed a large semi-fluid bilious stool. 
Effects of opium passing off. The tynapanitis is decidedly less, 
and the respiration is not so oppressed. Has passed urine for the 
first time, «*a sponte. No vomiting, and only slight hiccough. 
Pulse 142, and very weak. Face is covered witn cold perspiration, 
though the teinperature of the extremities is natural. Continue 
brandy and beef-tea during the night ; and half-drachm doses of the 
spir. ammon. aromat. are to be given if there is any appearance of 
sinking. 

29th. — Nurse states that the patient dozed during the night, but 
was at times very weak, and, in consequence, ammonia was. freely 
given. In the morning she appeared a little better, pulse 130, and 
weak ; abdomen still distendea, though not so much so as yester- 
day. The wound, I find, has not united as well as I thought it 
had, as, on pressure being made over the abdomen, a dark-coloured 
foetid fluid escapes at several points, with bubbles of gas. On 
examining the wound I found sometliing projecting at the lower 
part, and with a little care I extracted a portion of the foetal mem- 
oranes about twelve inches long, black ana intensely foetid. Several 
clots and an immense quantity of fluid were discharged after its re- 
moval. I cut, but did not remove, the lowest suture, with the intention 
of giving free exit to the discharge. Lochial discharge is mode- 
rate in quantity, and foetid. Bowels again open, and urine passed 
freely. Ordered a grain of opium at once, with a continuance 
of brandy, beef-tea, and eggs. In the evening she had altogether 



1864.] DR ANDEBSON'S CASK OF CiESAREAN 8E0TI0N. 47 

improved in appearance, and said she felt better. Pulse stronger^ 
124. 

30^ — Was restless during tbe night, and the bowels have acted 
five timeS; the stools being very yellow and semi-fluid. A grain 
of opium was given at eleven last night, and another at three this 
morning. Ammonia was also freely given in consequence of great 
debility. Free discharge of fluid is taking place n-om the lower 

Ejt of the abdominal wound. Pulse 118, and stronger. Slight 
ccough occasionally. 

Evenina. — ^Bowek have acted three times to-day, though opium 
has been nreely given. Complains of much gripingin the abdomen, 
though it is softer and much less distended, llemoved another 
piece of membrane from the wound, about three inches in length, 
roultice to be applied to abdomen, and one grain of opium given 
at once, and repeated at three A.M. if necessaiy. Pulse 120. 

Isi May. — Though restless during the earlier part of the night, 
was easier at three, and, in consequence, the ^ill was not given. 
Much troubled by niccough, which ammonia, in small doses fre- 
quently given, relieved. Bowels have not acted again. Patient is 
now comparatively free from pain ; abdomen is gradually reducing 
in size ; clots^ with foetid discharge, pass freely from the wound, and 
also per vagmam; pulse 120; tongue moist. Dressed wound, 
which looks healthy, with sol. chlor. sodae. Opium, gr.i., statim ; 
and brandy and l>eef-tea cid libitum. Asked for, and smoked a 
cigar with much pleasure. 

Evening. — Very low to-night ; pulse 130 ; feet cold ; voice very 
faint; cold perspiration on the face; tongue dry; much thirst. 
Drachm doses of spir. ammon. aromat. to be frequently given with 
the brandy. 

2cL — Passed a very restless night, with much pain in the abdo- 
men, cold feet, and frequent hiccough. Was only kept alive by 
the continued administration of brandy and ammonia. Says she . 
feels much easier, thopgh she is veiy restless and much troubled 
with hiccough. (Jovered with profuse perspiration ; pulse 134, and 
very weak ; tongue dry ; discharge very foetid. Ordered a mixture 
of chloric aetlier and ammonia to be frequently taken. 

Evening. — Has vomited twice, being the first time this symptom 
has appesured since the day after the operation. Bowels have acted 
once. Takes her nourishment and stimulants well. Continue 
medicine. 

Sd. — ^Another bad night, though the patient seems a little better 
this morning. As there was a good deal of pain during the night, 
a grain of opium was given. One large wateiy bilious stool nas 
been passed. Pulse 122. Discharge from abdomen is paler, not 
so foetid, and less in quantity. Tongue moister. 

Evening. — Has vomited once to-day, and the bowels have acted 
three times. Had a grain of opium at four this afternoon. Pulse 
184. Frequent hiccough. Face, neck, and thorax covered with 
cold sweat, though the extremities are warm. 



48 DR Anderson's case of c^esarean section. [july 

4eA. — Frequent doses of ammonia had to be given last nighty as 
she was very weak. Bowels have acted three times. Pulse is 
stronger this morning, and 130 ; skin warm, and tongue moist^ 
though red at the tip and edges. Abdominal dischar^ is senn 
purulent and firee from foetor. As the patient complaint of much 
griping pain in the abdomen, I ordered the following mixture : — 
9 Lic^. opii sedat. 3j. ; Spir. ammon. arom. et Spir. Lavand. co. 
Si 5ij. ; Mist Cretee. ad §viij. — M. Capiat gj. o. 2 h. Removed 
three of the sutures, and apphed strips ot plaster. About one inch 
of the lower end of the abdominal wound is unimited, and gapes 
widely, and through it can be seen the edges of the uterine wound, 
presenting a healthj granulating appearance. 

Evening, — Much more cheerful, and complains less of the griping 
and hiccough. Bowels have onlj acted once during the daj. 
Lochial discharge quite free. Pulse 130. 

5th. — ^Doing well, though pulse is high, 134. Dressed wound, 
which looks healthj, and removed three more sutures. Medicine 
to be continued, as there are still a few tormina. 
Evening. — Pulse 144. 

6rt. — Morning, prdse 134, evening, 122. Can sit up in bed 
without assistance, and seems altogether better. Wound looks 
well, and is skinned over in one or two places. Removed another 
suture, and re-applied strips of plaster. As the patient complained 
of uneasiness in tne throat, I examined it, and found on the soft 
palate several patches of white membrane easily removed, and 
closely resembhng the diphtheritic exudation. Tongue red and 
irritable. Ordered a chlonde-of-soda gargle. 

Ith. — Weaker to-dav. Pulse 124. Throat better. Breasts still 
flaccid, though the cnild has been frequently applied to them. 
Removed another suture, and placed a pad on eitner side of the 
abdominal sinus with stnps of plaster, in order, if possible, to bring 
the edges together. The profuse purulent discharge from the abdo- 
men, though quite healthy and free from foetor, seems to be exciting 
a hecticcondition. 9 Potassse chloratis, 3j. ; Qjuins disulph., gr, xij. 
— M. Divide in chart, vj. Capiat j. ter in die. 

8^. — Throat better, though patches of false membrane have 
extended to the inside of the cheeks. 

%ik. — Much griping pain in the abdomen during the night. Ten 
grains of Dover s powoer were given by the nurse, but were soon 
after vomited. Discharge verv nree. rulse 122. Applied a lar^ 
pad over the whole of the aodomen, and over this a bandage, in 
order, if possible, to procure deep-seated adhesions. Tympanitis 
has quite passed off. 

Evening. — Griping still continues. Ordered one grain of opium 
at once, and warm fomentations to the abdomen. 

12«A. — Since last report has been going on pretty well, though 
very weak. Pulse has ranged between 110 ana 130. Abdominal 
discharge is now decidedly less, and appears to be stopping. In 



1664.] DR ANDERSON'S CASE OF C.SSAREAN SECTION. 49 

consultation with Dr Bowerbank we resolved to close the abdominal 
smos^ if possible. The sinus — ^large enough to admit a small wal- 
nut — ^gapes widely, and allowsM view of the upper part of the uterus^ 
and one or two folds of intestine of a pink colour mottled with dark 
patches. I passed a silver wire deeply through the abdominal 
walls and peritoneum at the middle of tne sinus, and fastened either 
end of it to a piece of pencil in the manner of a quilled suture. 
Two other sutures were then passed through the skin and muscles 
at points equidistant above and between the deep one. The parts 
were thus accurately brought in apposition. 

Evening. — Skin warm. Has vomited a little. Complains of pain 
at the pomts of suture. 

13<A. — Doing pretty well. Has had a good deal of bilious vomit- 
ing. Pulse 120. Ordered 9 Sodse bicarb., Bismuthi trisnit, afi 
5s8, ; MorphisB acet. gr. j. — M. et divide in chart vj. Capiat j. ter 
in die. 

15«A. — ^Vomiting quite checked. One of the sutures was cut out. 
Adhesion has taken place, only to a slight extent, at the upper 
part of the sinus, and sero-purulent fluid oozes out between tnose 
still remaining. Bowels confined. Ordered a dose of oil. Patient 
seems cheerful, and eats and sleeps well. 

16<A. — Oil acted well. The nrst stool passed contained a good 
deal of clotted blood. Removed the two other sutures, as thej 
appeared to be of no use, and applied a strap of plaster. Sinus is 
much in the same state as it was before the sutures were introduced. 

20<ft. — Getting on well. Sits up in bed for several hours daily. 

22df. — ^Was called late to-night to the patient, who I was m- 
formed was worse. On seeing her, I founa that she had suffered 
from rigors occasionally during the last two days. Has vomited 
during the day a large quantity of bilious fluid. Discharge from 
abdomen has nearly ceased. Complains of much jDa,in at a point 
about two inches below the ribs on the left side. On examination, 
I found that at the seat of pain there was an indurated swelling, 
about three inches in diameter, very tender on pressure. All other 
parts of the abdomen were soft and free of tenderness. The skin 
was hot, and pulse 120, of good strength. Ordered a large poultice 
over the abdomen, and $ Pulv. opii, gr.iss. ; Bismuthi, Sodas 
bicarb., aa gr. x. — M. et fiat chart statim sum. 

23df. — Patient is easier this morning, though she vomited fi«- 
auently during the night. Skin cool, and pulse not so rapid. 
Swelling in abdomen still very hard and tender. As the bowels 
have not acted for two days, ordered a dose of magnesia. 

24<A. — Going on pretty well. Abdominal swelling not so pain- 
ful or tense^ though it has a feeling of deep-seated fluctuation. 

26^. — Nurse reports that while patient was turning round in bed 
last night, she felt something give way within the abdomen, and 
inmiediately a gush of fluid took place through the sinus to the 
extent of at least a pint The fluid discharged was sero-purulent, 

VOL. X.— NO. I. a 



50 DB ANDERSON'S CASE OF CfiSABEAN SECTION. [JULT 

jellowish in colour^ and smelled very offensively. This morning 
the patient seems much easier, and the vomiting which has so much 
distressed her for the last three or four^days has qnite stopped. At 
the point of swelling in the abdomen there is a depression of about 
two inches in diameter, surrounded by indurated edges, presenting 
to the fingers much the same feeling as is noticed in sanguineous 
tumours of the scalp resulting &om an injury. 

28th. — Doing well. The abdomen is softer, less tympanitic, 
and free from pain on nressure. Sinus has much contracted, and the 
discharge, though stiu going on, has much diminished. Uterus is 
firmly adnerent to the lower part of the abdominal walls^ and is 
drawing them in. 

4A June. — B^ the request of its relatives^ the child was dis- 
charged to-day in good health. Mother is doing well, and able to 
take a daily walk in the grounds of the institution. 

10th. — I'he abdominal wound is now perfectly cicatrized over, 
except where the sinus existed. At this point there is a small 
papilla, which on pressure exudes a drop oi serous fluid. Mother 
was this day discnarged, at her own request, in a good state of 
health. 

5th September. — I have to-day seen both mother and child in a 
State of robust health. The mother is enabled to pursue her daily 
avocations as well as she did before her confinement. The sinus 
has completely healed, and union is perfect at all points of the 
incision. She has now a plentiful supply of milk, having procured 
it by drinking a decoction of the leaves of the cotton-tree {Ghsay-' 
piufn Barbadenee)^ in accordance with the advice of some old 
woman. This decoction is well known in this island as a galacta* 
gogue of great power, far superior to the leaves of the BidnuB 
ccnnmunis. 

Remarka. — ^In tropical climates^ as is well known, the process of 
parturition usually takes place with comparative ease and freedom 
from danger. The extreme cases of distortion, requiring instru- 
mental interference, so frequently met with in tne mother country, 
especially in the manufacturing districts, but rarely occur in this 
island ; and the majority of labour cases are in the hands of mid- 
wives, who, notwitlistanding the injurious practices they pursue- 
both during and bS^ax labour, generally bring them to a successful 
termination. 

Diseases affecting the bony pelvis, such as rickets and tumours, 
are seldom seen ; and the Cesarean section has not been required in 
this city, nor, as far as I have been able to ascertain, in the island, 
within tne memory of any one living. It was therefore a matter of 
some interest to ascertain the origin of the malformation that gave 
rise to the necessity for this operation.. This was a matter of some 
difficulty, for the mother of the patient was a woman not particu- 
larly enaowed with intelligence, and very forgetful of past events. 



1864.] Vn AMDEBSON'B case of OCaABEAN 8ECTI0V. 61 

I maiMged, however, to ascertain that her daughter had neyer met 
with any accident, and had always been healthy, except for a period 
of about three months, when she was under a year old. At this 
time the child got very thin, and would not nurse well* She was 
taken to a medical man, who stated that her ''bones wanted 
strengthening," and he gave some medicine, as he said, '' to run 
through the bones." Under his treatment the child rapidly 
imnroved in health, and from that time to the present has not 
haa a day's illness. I suspect that the child had an attack of 
rickets, and that then the distortion took place which was the 
cause of so much trouble when she became a parturient woman. 
But whatever the cause was, when the patient came under my 
care in active labour, no doubt could exist as to the only means to 
be employed to procure delivenr. The three methods usually 
resortea to in cases of contracted pelvis (viz., version, forceps, or 
craniotomy) were all utterly out of the question, and the only 
chance of escape for both mother and child was in the performance 
of this operation. This decision was arrived at after repeated and 
careful examination by myself, in conjunction with the two oldest 
and most experienced medical practitioners in this city. In accord- 
ance with what is generally considered as the principal element of 
success in those cases which have resulted favourably, we resolved 
that no time should be lost, believing, as we did, that if the opera- 
tion was performed whilst the patient's powers were still unim- 
paired, she, toother with her child^ would nave a reasonable chance 
of life, while, if we resorted to the meffectual trial of other means to 
relieve her, much precious time would be lost, and she would have 
ultimately to be subjected to the dernier resort of operative mid- 
wifery, under circumstances which would give but little promise of 
a successM issue. I therefore operated within two hours of my 
first visit. The operation was in itself simple enough, only two 
circumstances having occurred during its performance which gave 
me any concern. One of these was the rapid escape of the liquor 
amnii immediately the cavitjr of the uterus was opened, in conse- 
quence of the strong contraction of that organ. Notwithstanding 
all the care exercised by Drs Bowerbuik and Fiddes in keeping 
the edges of the abdominal wound closely applied to the uterus, 
much of the fluid escaped into the abdominal cavity. This was^ I 
have no doubt, in a great measure the cause of the subsequent in- 
flammation and the purulent discharge that went on for so many 
weeks after delivery. The other circumstance was the slight thoura 
persistent hsdmorrhage that took place from the lower edge of tne 
uterine wound after the extraction of the child and secundines. 
This, though slight in amount, I was glad to find checked by the 
application of a little cold water. The mere loss of such a small 
quantity of blood would not in itself have produced any serious 
effects, but I was anxious to avoid if possible the formation of any 
clots in the abdominid cavity acting as foreign bodies. Small clots 



52 DR ANDEBSON'S case of CiESAREAN SECTION. [JULT 

came awaj subsequently through the wound, but I am inclined to 
think that thej came from the uterine cayitj, as thej followed the 
removal of portions of the foetal membranes. 

The operation being over, and the patient placed comfortably in 
bed, with a good pulse, two great risks were in a measure over, viz., 
shock and haemorrhage ; but many others had to be passed through 
before recovery took place, — severe peritonitis, exhaustion occasioned 
by long-continued purulent discharge, diarrhoea ; and when con- 
valescence appearea to be fairly established, the formation of an 
acute abscess which burst into the abdomen. From each of these, 
as they successively appeared, I feared a fatal issue, and it was a 
matter of surprise to me that the patient got through them all. 

The two points most worthy of remark in the after history of the 
case, are the long-continued abdominal discharge, and the abdominal 
abscess. Discharge of purulent matter went on from the peritoneum, 
through a sinus large enough to admit a walnut, for nearly four 
weeks after the operation. Through this sinus I could daily 
watch the gradual cicatrization and involution of the uterus, and 
the peristaltic action of the intestines. It is rare, I believe, for the 
contents of the abdomen to exhibit such tolerance of free exposiire 
to the air as occurred in this case ; but I have noticed that in this 
climate wounds *of serous surfaces, and their free exposure to the air, 
are not attended with the same dangers as in England. The 
abdominal cavity of my patient seemed converted into a large 
chronic abscess, the walls and contents of which were continually 
secreting pus. That this pus did not come solely from the uterine 
wound was shown by the fact that pressure on any part of the 
abdomen . brought it away in a gush. This discharge went on 
until the twenty-seventh day after the operation, when an acute 
abscess began to form. Three days later this dischar^d a pint of 
stinking pus through the sinus, — ^a result which I hardly expected, 
for I imagined that its exit would be through the intestines. The 
stools were accordingly carefully examined daily, but with a ne^ 
tive result. After the abscess discharged, convalescence was rapid, 
and the patient with her child was dismissed (both in good health) 
on the forty-sixth day after the operation. 

The medical treatment pursued after the operation was of the 
simplest kind. Besides the free administration of opium and 
ammonia, but little medicine was given ; believing as I did that if 
recovery was to take place it would rather be by carefrd nursing 
and attention to all means capable of supporting the strength of the 
patient than by anv heroic measures tiiat I could adopt. The 
patient was kept by herself in a detached building in th^ institution, 
which is favourably situated in the outskirts of the city. Two 
carefril and experienced nurses were in constant attendance on her 
day and night, and it is to their unremitting care and kindness that 
much of the successftil termination of the case is owing. With the 
exception of the first two or three 'days, the patient took and 



1864.] DB Anderson's case of cjesarean section. 53 

digested daily three pounds of beef steamed down into the strongest 
essence possible* Eggs and milk were also given, with plenty of 
brandj. Of the latter she consumed for some time more than a 
pint daily, and its beneficial effects in combination with ammonia 
were well marked. Frequently, when she appeared almost " in 
articulo mortisy^ with rapid, nearly imperceptible pulse, and cold 
sweat standing on th^ face and upper pturt of the body, a good dose 
of brandy and ammonia roused her flagging powers, and tided her 
on for an hour or two, when it was again repeated with equally 
beneficial effect. One favourable sjmptom was present throughout, 
and that was her capacity for receiving and digesting any amount 
of nourishment that could be given. 

If called upon to operate in a similar case, there are two points 
in which I would act differently. In the first place, I would 
rupture the membranes per vagmam previous to operation. By 
doing this all risk of escape of the amniotic fluid into the cavity 
of the abdomen would be avoided : a matter, I think, of some 
importance. The only objection I see to this method is, that 
if the waters were discharged spme minutes previous to opera- 
tion, the uterus might be strongly contracted round the child, and 
more force be required in its extraction. Experience, however, 
only can show whether this objection is well founded or not. 
Another point is with regard to the mode of bringing the edges of 
the abdominal wound together. If I had another case I would 
certainly pass five or six sutures of wire deeply through the peri- 
toneum, and instead of tying or twisting them, fasten them on 
either side to an elastic bougie, in the manner of the quilled suture, 
as used in the perinseum. The substance used instead of the quills, 
whether bougie or anything else, should be large — ^to produce deep 
pressure on the parts included in the sutures, and elastic — to allow of 
the abdominal oistention that must to a greater or less extent take 
place after the operation. A portion of a long gum-elastic rectum 
Dougie would answer very well. Of course, in f^dition to the deep 
sutures, superficial ones should also be inserted. 



$art Seconlr. 



REVIEWS. 



On the Arcu8 Senilis, or Fattu Defeneration of the Cornea. By 
Edwin Canton, F.R.C.S., JPresident of the Medical Society of 
London, etc., etc. London : Harwicke : 1863. 

The frequency and importance of fatty degeneration have only 
lately been recognised. A few years ago, all that was known re- 



54 MR CANTON ON THE ARCUS SENILIS. [JULT 

^ding fat as a manifestation of disease, was connected with its 
aeposition in abnormal quantity in the cellnlar tissue, its presence 
in the form of layers around mtemal organs, or its existence in 
Tarious situations in the shape of distinct tumours. We now 
know that the elements of almost all the tissues of the bodj may 
be converted into fat, and that fatty degeneration is one of the 
most important of the morbid processes ; climacteric disease, there 
can be no doubt (as was indeed suggested many years ago by 
Sir Henry Holland), depending essentially on the occurrence of 
a change of this kind in the heart, the arteries, and various other 
organs. 

The condition called arcus senilis has been long known ; it con- 
sists in the presence of an opaque ring of a whitish or yellowish 
colour around the margin of the cornea. Of the cause of this 
appearance, however, various explanations were formerly given. 
Thus it has been ascribed, as Mr Canton points out^ to an unnatural 
dryness of the parts ; to coagulation of the fluids m the substance 
of the vessels ; or to the presence of an exudation between the fibres 
of the cornea. But we now know that it consists of a fatty de* 
generation of the substance of the cornea; and to Mr Canton 
belongs much of the credit of having clearly established this fact. In 
itself the arcus senilis is not of much importance; in its earlier 
stages it may long escape observation ; and, even when fully formed, 
it causes no pain, impediment to vision, or other inconvenience. 
The condition, however, becomes of much more interest when 
looked upon as an index to the state of internal organs. We 
cannot in the early stage recognise the fatty heart, or the athero- 
matous artery; but a veiy slight change in the tranroarent cornea 
will attract the attention of me carefm observer. Some, in our 
opinion, attach too much importance to the aicus senilis as a 
diagnostic sign, for cases not very unfrequently occur where the arcus 
has been well marked, yet where little or no fatty degeneration of 
internal organs is found ; or on the other hand, where the cornea 
has been transparent, yet the heart and arteries are in a state of 
advanced degeneration. This, however, amounts to no more than 
saying that tne sign is not infallible, and in the majority of cases it 
may, we fully believe, be depended on. The following passage 
quoted by Mr Canton firom Mr Paget, expresses, we believe, very 
accurately the value of the arcus senilis as a dia^ostic si^n: 
^^ The arcus seems to be, on the whole, the best indication which 
has yet been found of proneness to an extensive, or general fatty 
degeneration of the tissues. It is not, indeed, an infallible sign 
thereof: for there are cases in which it exists with clear evidence of 
vigour in the nutrition of the rest of the bodv ; and there are others 
in which its earlv occurrence is due to defective nutrition conse- 

2uent on purely local causes, such as inflammatory affections of the 
bopoid, or other parts of the eye ; but, allowing for such exceptions, 
it appears to be the surest, as well as the most visible sign and 



1864.] MB CANTON ON THB AB0U8 8ENIU& 65 

measore of those primary degeneTations which it has been the chief 
object of my two last lectnres to describe/* 

The volume before us is devoted to an account of this condition, 
and of some of the other changes in the economy with which it is 
associated. It is interesting, and contains important matter, but it 
is certainly too long. Several of the chanters might with ereat 
advantage have been shortened, and the Dook would have been 
more interesting to the reader, and not less creditable to the writer, 
had much of the accessory matter been omitted* We have also to 
complain that the correction of the press has been in some places 
most carelesslv executed ; one French quotation in particular, on the 
two-hundredth and fifteenth pafi;e, literally teems with errors, and 
Dr Gairdner's name is persistently misspelt Gaidner. The punctua- 
tion, also, is most inaccurate : amon^ other peculiarities a comma is 
invariably inserted after a conjunction, so that the appearance of 
some of the sentences is most singular. The two following quota- 
tions will illustrate our meaning : '^ The coloration of the crystalline 
lenses, the gray hairs on the temples, fatty degeneration, and, ossifi- 
cation of the laryngeal, and, costal cartilages, interstitial absorption 
of the necks of the thigh-bones, atheroma, and, calcification of the 
arteries, etc., supply us, also, with instances of this symmetry of 
change, gradually, but, surely impressing the body, as years steal 
on, and, stamp it with the indelible ma^ of the decline of life." 
— '^ The ezuaed material may, however, remain, and, undergoing, 
or not, vascularization, becomes converted into new tissue : or, pass- 
ing into low forms of fluid, or, solid is, now, to be regaraed as 
d^enerate : and, amongst other phases determined in this degenera- 
tion, we recognise the^^, and, caloareous.^^ 

Such carelessness in punctuation, and we may add in composi- 
tion, detract veiy materially from the pleasure we might have in 
reading the work. 

The first chapter of Mr Canton's book contains a minute general 
and microscopical description of the arcus senilis. The condition 
in question commences as a slight diminution of the transparencnr 
of some point of the margin of the cornea, which gradually extendui 
so as to assume a semilunar form. Two arches are formed in each 
eye, one at the ^per, the other at the lower border of the cornea. 
There is some difference of opinion as to which of these arches 
forms first, but Mr Canton maintains, and we believe maintains 
correctly, that, as a general rule, the first formed arch is that which 
occupies the upper se^ent ot the cornea. After a time these 
arches meet ana constitute an ellijpse or zone around the cornea, 
though a narrow rim of unaffected tissue generally remains external 
to the arcus. On microscopic examination, oil-globules are found 
in the corneal cells, in their processes, and in the inter-cellular or 
inter-lamellar substance. The following is the method which Mr 
Canton recommends for demonstrating t£e fatty nature of the arcus 
senilis: 



56 MB CAKTOK ON THE ARCUS SENILIS. [JULT 

*' Haying selected a perfectly fresh eye in which the arches are well-marked, 
or, a circle exists, cut, circularly through the sclerotic at the distance of a few 
lines from its junction with the cornea, and, detach the two, conjoined, from 
the iris, ciliary muscle, etc. The piece removed is to be divided into four 
equal parts, by two incisions intersecting at the centre of the cornea. Pin 
each triangular portion to a wax tablet, and, let all become dry in a current of 
air. After drying, remove, ^carefully, with a sharp knife, a very thin * shaving * 
from the edge of the preparation ; place it on a slide, in a orop of water to 
which has been addea a little acetic acid, and, having (after a few minutes) 
covered the object, proceed to its investigation. 

" Examined by tne microscope, first, with a power of 60 diameters, the 
specimen shows the mbatarUia propria, at a short distance from the sclerotic, to 
be of a very light-brownish hue, and, its fibres appear as though matted, or, 
confused together. The depth of this tint is, ordmarily, greatest towards the 
anterior, elastic lamina, and thence, declines, more and more, as it approaches 
the membrane of Decemet. This is seen to be the case, more especially, if the 
arcus, still, retains the bluish, or, bluish-white colour which is characteristic of it 
in the earlier stages of its formation, and, when fatty degeneration has not, as 
yet, involved the entire thickness of the proper substance of the cornea. In 
proportion, however, as this part becomes more invaded, and, the colour is seen 
to have changed to that of a dense white, or, ochery white, so will it be found, 
under the microscope, that fatty degeneration has extended to the deeper 
lamellfiB of the cornea, and, in its whole thickness it, now, presents the lignt- 
brownish tint I have already referred to. 

" It would, thus, appear that the change, ordmarily, commences in the super- 
ficial laminae, and thence, extends, by degrees, through the whole of the sub- 
stantia propria at this spot." 

On using higher powers the affected tissue will be found fiiU of 
fine oil-globules. An interesting observation made by Mr Canton 
is^ that the arcus senilis is often associated with fatty degeneration 
of the muscles of the eye, atheroma of the ophthalmic arteries and 
their branches, as well as with similar changes in distinct but more 
important localities. 

The second chapter treats of the arcus senilis as influenced by 
hereditary predisposition. As a general rule it does not appear till 
after fifty years of age ; it may, however, occur sooner, m conse- 
quence of great general debility, of disease or injury of the eye, or 
tne existence of an hereditary predisposition. An interesting case is 
recorded where the arcus senilis was well marked in a lad of 
sixteen years of age, where the tendency to its formation was 
probably hereditary ; or where we should rather say the lad had 
inherited from his parents a feeble and debilitated constitution, one 
of the si^s of which was the occurrence of fatty degeneration of 
the margm of the cornea. 

In the third chapter Mr Canton considers the arcus senilis in 
reference to its being occasionally produced by disease or injury of 
the eye. Severe choroiditis, when it continues for some time, very 
frequently gives rise to it. No doubt, the explanation given by Mr 
Canton of this connexion is the correct one, namely, that the 
inflamed and swollen choroid presses upon the bloodvessels which 
supply the cornea, its nutrition is consequently impaired, and fatty 
degeneration takes place. 



1864.] MB CA2IT0H ON TH£ ASCUS 8KNIUS. 57 

The next chaDter is headed ^^ on the oocasional non-oecurrenoe 
of the arcns in old age ;" but though it extends to twenty-six pages^ 
the result arrived at maj be very briefly stated. It would appear 
that though the occurrence of tlie arcus senilis in old people is the 
rulci some persons reach a very advanced age without exhibiting 
any, or but very slight, traces of it. 

The fifth chapter professes to treat of the connexion between the 
arcus senilis ana fatty and calcareous degeneration of the costal and 
laryngeal cartilages ; but the greater portion is devoted to a minute 
description of the anatomical and histological changes which take 
place m the cartilages. 

The two following chapters treat of the occurrence of the arcus in 
the intemperate and the gouty, but they do not seem to call for any 
special remark. 

The last chapter consists of ^^ general and additional observations 
on the arcus, and its disappearance under constitutional treatment.'* 
Under this heading the author speaks of the causes and characters 
of defective nutrition in general, and illustrates his statements by 
cases where patients in this condition were the subjects of the arcus 
senilis. We must conclude our notice of Mr Canton's work by the 
following extract, which is interesting as showing that while the 
existence of the arcus is a sign of a debilitated constitution, its 
gradual disappearance ifkay nSord evidence that the system is 
regaining part of its former vigour. 

"There can be no doubt that much maj be accomplished, in process of time, 
by means of medical treatment, where it is ascertained that such conditions are 
present as tend towards a general, or, systematic decadence ; and, in which is, 
not uncommonly, implied an atrophying state of many, and, diverse t'ssues. 
Numerous cases, of tnis description have come under my observation, daring 
the last twelve years : and, it is extremely interesting to have had occasion to 
notice that, paripassuy with amendment of health has been the disappearance of 
the orcitf, in those instances where thiu symptom was present, and, by its 
presence had afforded the clue to the peculiar character of the mischief in 
progress. 

" Being anxious to ascertain whether others had made the same observa- 
tion as myself, I applied to Dr R. Quain, who informed me that he, too, had 
seen several examples of the disappearance of the arcus ; and, at the same time, 
he kindly furnished me with the following case, which, as he observed, will 
illustrate many of a similar character : — 

" A clergyman, aged 46, came under my notice in March, 1851, as proposing 
his life for insurance. He was tall, portly, stout, in proportion to his height, 
and, one who, in common talk, woula be described as * a fine, healthy-looking 
man.* 

" A gknce at his features, placed in a good light, happened to detect a well- 
marked, though not broad, arcus senilis. This was tne key to the following 
short Imtory. He had been accustomed, until Ifive, or, six years before I saw 
him, to active pursuits both in his profession, and. out of it. Then, his wife 
became the subject of a painful, ana, protracted disease, which imposed upon 
him much anxiety, and, &tigue. From this state he was relieved by her death ; 
but, only to be involved in a Chancery suit. He had endured these troubles for 
five years before his visit to me. He said that he was not conscious of suffer- 
ing from any distsase ; a little inquiry, however, showed that he was no longer 
equal to any exertion, a hill or a stair ascent rendered him faint, and, breathless. 

VOL. X. — NO. I. H 



58 MK CANTON ON THE ARGUS SENILIS. [jULY 

His pulse was weak, and, compressible. His functions, generally, seemed toler- 
ably well performed, save that the hearths sounds were feeble, and, languid, and, 
that his digestion was occasionally somewhat out of order. After a short 
interview, he thus summed up his feelings, — * I <io feel that I am wearing out.* 
Some suggestions were made to him for his future guidance, and, he came again 
under observation in May, 1852 (after a period of 14 months). His Chancery 
suit had ended to his satisfaction soon after his last visit ; and, he had since 
devoted much of his attention to the restoration of his lost strength, and, 
successfully. 

" He was now, he said, ' ten years younger, and, equal to any amount of 
exertion.' There was much trutn in his observation. He was evidently now 
vigorous. His pulse, and, heart's action were stronger. The arcus had fJraost 
altogether disappeared, and, would not have been perceived had not a previous 
knowledge pointed to its existence. His life was, now, accepted at a moderate 
increase of premium. 

"This case seems to show: — 

" 1^. The value of the arcus as an aid to a diagnosis. 

" 2c%. The circumstances which, impairing health, tend to the production of 
that premature deca^, or, degeneration recognised as ' fatty. ^ 

" 3c%. The possibility of arresting, and, removing this condition.*' 



A Manual of Minor Surgery. By John H. Packard, M.D., 
Demonstrator of Anatomy in the University of Philadelphia. 
Philadelphia : Lippincott and Co. : 1863. 

It is a deeply-rooted principle in every well-constituted mind, to 
be prepared to cavil at, and object to, anything or anybody which 
has been praised or held up as a model for imitation. 

The good boy of the stoiy-book, and the justice of Aristides, 
become equally wearisome. The scene over which the guide-book 

Sies into raptures only gives rise to invidious comnarisons, and this 
anual of Minor Sur^ry, on the same principle, mi^ht almost 
change the usually placid reviewer into a malignant wielder of the 
tomahawk and scalping-knife. For it comes forth to the world 
having been sat upon by a board — a board of military surgeons, 
and it has received their favourable verdict ; a verdict, too, which 
not only pronounces on its absolute merits, but also gives its rela- 
tive rank — the board " being satisfied that it is a better text-book 
upon the subject than any of the treatises with which the American 
market has hitherto been supplied." Really, in its bad grammar, 
in its cool assumption, in ks mercantile view of the subject, this 
finding of the board mi^ht rouse antagonism in the heart of the 
quietest Quaker in Philadelphia. 

Were it not for the board and the reminder it gives us of the cool 
manner in which the ^^ American market does supply itself ^^ with 
books, even by English authors, this inoffensive little work might 
escape any hostile criticism. It is a careful enough compilation, 
choosing rather to describe all the plans of performance of an^ 
minor operation, than to point out or describe the beat plan. It is 



1864.] DB Packard's manual of mikob suboebt. 50 

tempered to the intellectcial level of a hospital orderly, rather than 
of even a janior student 

The chapter on bandages, includine an analysis of Major's book 
on the use of handkerchiefs, is carefiu and intelligible. Fractures 
are folly treated of; but taking at random the account of that most 
important set of fractures of the shaft of the thigh-bone, we find no 
fewer than ten plans described, all very various and complicated in 
detail, and all involving the principle of constant counter-extension 
bv weights, plasters, bandages, elastic bandages, pulleys, etc., some 
01 which ^' require to be changed daily ^ the perinseum to be washed 
with whisky, and carefully dried before re-application." 

At page 69, and also in a footnote, we fina the grooved director 
put to some of its most objectionable uses — to be passed into the 
sheath of an artery (in the operation of li^ture), and then to be 
bent and passed under the artery, as a guide to the probe carrying 
the thread. 

In the chapter on sutures, there is an omission of minor import- 
ance, and perhaps merely accidental, but still curious in an American 
work, — ^there is no notice whatever taken of any shape of needle 
suited for conveving metallic sutures, except the old flat curved 
needle. Have the needles of Professor Lister or Mr Price not yet 
found their wajr to the country to which we owe the great practical 
improvement involved in the substitution of metallic for organic 
sutures? 

The work is ftilly illustrated and very neatly got up, and clearly 
printed* With the imprimatur of an army board, we doubt not its 
merits as an instructor of dressers and hospital orderlies will be 
fully tested in this weary war. 



Ten Years of Operative Surgery in the Provinces. By AuGUSTiN 
Pbichabd, F.R.C.S., Surgeon to the Bristol Boyal Idirmary, 
etc Part 11. London : Kichards : 1863. 

This is the second and concluding portion of a work which has 
been already noticed in these pages, and it fully bears out the 
favourable opinion expressed of the part previously published. 

This volume contains autoplastic operations, excisions, tumours, 
and amputations. The excisions of joints are too few in number to 
avail much as a contribution to statistics. Of three cases of exci- 
sion of the knee-joint, all recovered after more or less tedious con- 
valescence, with useful limbs. All, however, were well selected 
cases in adults, between the 8^s of twenty and thirty-five. Mr 
Prichard has been led to pre^r the semilunar to the H-shaped 
incision. 

In these days, when it is so much the fashion in some circles to 
decry the results of operative surgery, it is refreshing to find such 



60 MR PBICHARD'S OPERATIVE STJRaEBT IN THE PROVINCES. [jULY 

statistics^ contradicted in their own &vonrite field, in so far at least 
as Mr Prichard's practice is concerned, for out of eighteen primary 
and secondary amputations of the thigh, only two cases proved 
fatal, one of which was a child of two and a-half years, who had 
been run over by a cart, and also suffered severely rrom whooping- 
cou^h. 

We cannot go more into detail, but in one particular especially 
this little volume, as well as its predecessor, is worthy of all honour ; 
we mean the manly honesty which records both the operations 
which have proved successful, and those in which mistakes in 
diagnosis or treatment may have been made. 

There is nothing of a mere manual or compilation about this 
work ; it is the honest record of ten years of honest labour, and 
modestly conveys many practical hints of great value. 



On the JSestarution of a lost Nose by Operation. By John 
Hamilton, Surgeon to the Richmond Hospital, etc. London : 
John Churchill and Sons : 1864. 

When the notary, the hero of Edmond About's grotesque novelette, 
was in despair, regretting his lost nose, his rival and conqueror 
consoled him with the thought that in Paris there were skilfal 
surgeons who had infallible secrets for the restoration of parts 
mutilated or destroyed. Ireland, our author tells us, has up to 
this time been behind Britain, and far behind the Continent, in 
this branch of operative surgery, and the present monograph is a 
description of what Mr Hamilton nas done in the special department 
of rhinoplastv. 

A short historical account is prefixed to the main body of the 
work, which consists of a full ctescription, with copious woodcuts, 
of ten cases, in which new noses were made to supply various 
decrees of deformity. The loss in most of the cases was the result 
of lupus, iti two of syphilis, in one of cancer ; and the new features 
were obtained from the forehead by the Indian method. 

The chief peculiarity of Mr Hamilton's plan, in which it differs 
slightlv from others, is, that the central projecting portion of the 
flap which is destined to form the septum is small, and ends above 
in a point, instead of being either square or rounded. The methods 
of fixing the stitches, preparing uie foundation, and stuffing the 
nostrils, seem in no essential point to differ from those used, by his 
predecessors. 

The successftil results, as vouched for by the woodcuts, and by 
the testimony of the patients, seem in great measure due to the 
very careful preparation of the patients, by systematic and continued 
therapeutic and hygienic treatment. 



1864.] ANNALS OF MILITABT AND NAVAL SUBGERY. 61 



Anncds of AttHtary and Naval Surgery and Troptoal Medicine and 
Hygiene: An Annual BetraapecL London: Uhorchill & Sons. 
VoLL 1863, 

Thb namerons highlj-educated and acoomplished medical officen 
in the sister services have vast opportunities of observation, and 
jear by year are taking more advantage of these opportunities. 

The present volume consists of a selection of extracts or analyses 
of the more important of the contributions to medical literature by 
the medical officers of the army and navy, and promises to be the 
first of a most interesting and valuable series. 

A distinct part is devoted to each station of the army and navy ; 
and this arrangement, along with a most copious index, ^eatly 
facilitates reference, besides showing separately the healtn history 
of each command. 

Amid so much valuable material, selection is almost invidious ; 
but to some of us in Edinburgh, the very able medical journal of 
the ^^ Icarus" by Dr Macdonald has a deeper interest than its pro- 
fessional one, describing as it does the outbreak of yellow-fever in 
which a most promising young graduate and dear friend, Br David 
Maclagan, fell a sacrifice to his professional enthusiasm. 

The papers on Dysentery by Drs Ewart and Mackav — on Gun- 
shot Wounds by llongmore and Niell — on Syphilis by Marston, 
would be sufficient alone to stamp the book a valuable one. For 
officers on foreign stations, without access to medical libraries or 
facilities for transporting many volumes, this series, if continued, 
promises to be of extreme value. 

In outward appearance like the Abstracts of Banking or Braith- 
waite, it comes mto competition with no other work, nils a comer 
hitherto unoccupied, and will, we trust, meet with the success it 
deserves. 



PERISCOPE. 



8UR6ERY. 

ON THE EMPLOYMENT OF SUBCUTANEOUS INJECTIONS IN OPHTHALMIC SUSGEBV. 
BT PBOFESSOB VON ORAEFE. 

Professor Von Graefe lately delivered a series of clinical lectures on the 
employment of sabcutaneous injections in ophthalmic snigery, of which we pro- 
pose to give a brief abstract. His experiments have been only made with the 
acetate of morphia and the sulphate of atropine. The most nvonrable situa- 
tion for making the injections is the middle of the temporal region, and it is this 
which the Professor chooses under all circnmstances, unless there be some 



62 PERISCOPE. [JULY 

special indication, such as neuralgia or spasmodic phenomena, which makes it 
probable that some other point may be preferable. The integument should 
DC well raised from the subjacent parts, — the canula should be pushed into 
the cellular tbsue, and the skin should be closely applied around the canula, 
so as to prevent the return of the liquid injected. Tlie quantity of acetate of 
morphia employed in Graefe^s experiments, varied from the tenth of a grain to 
half a grain, — a fifth or sixth of a grain being the usual quantity. The solution 
contained four grains of the acetate in a drachm of distilled water ; it should 
be neuter, or very feebly acid. The physiological action is the same as when 
morphia is taken into the stomach, but in general it is better marked, and 
consequently the amount injected ought to be smaller by about a third than 
the quantity which would be administered internally. The action on the iris is 
interesting. Often at the end of a minute, sometimes not for half an hour, the 
special contraction of the iris {qpium-myosis) manifests itself. This contraction 
is best observed by comparing the dimension of the pupils with a moderate 
light. The degree and the duration of the myosis vary remarkably ; in a large 
number of cases it remains well marked for several hours, and disappears 
slowly. Sometimes in very irritable persons, spasm of the muscle of accommo- 
dation of the iris takes place ; when this phenomenon occurs, it is at an 
advanced period, at the end of the stage of irritation. The most important 
therapeutical indications of subcutaneous injections of morphia are, according 
to Graefe, the following : — let. In the case of traumatic injuries which have 
involved the eye-ball, soon after their occurrence, and when there is severe 
pain ; for instance, after the penetration of foreign bodies, superficial burns or 
wounds, the pain is more speedily allayed by the subcutaneous injection of 
morphia than by the instillation of solution of atropine between the eyelids. 
Professor Graefe is opposed to the application of leeches after the extraction of 
foreign bodies, after contusions, and after penetrating wounds ; he looks upon 
them as more likely to produce than to prevent inflammation and suppuration. 
2df, After operations on the eye, when they are followed within a short time by 
intense pain. Mj In the neuralgia of the ciliary nerves which accompanies 
iritis, glaucomatous choroiditis, and several forms of inflammation of the 
cornea. 4M, As an antidote for poisoning by atropine, an action which was 
pointed out by Mr Bexijamin Bell in 1857. 5A, In necualgic affections of the 
terminal branches of the fifth pair in the frontal region, not dependent on an 
affection of the eye. Qth. In different forms of reflex spasms, such as spasm of 
the eyelids in traumatic keratitis, and spasmodic contraction in the course of 
the facial nerve. 

In the case of injections of atropine, the greatest prudence is necessary. In 
some persons the sixtieth of a grain is sufficient to give rise to general 
B3rmptoms. In general the first dose injected should not exceed that quantity ; 
it may afterwards be gradually increased to the twentieth of a grain. Accord- 
mg to Professor Graefe, the occasions for the employment of atropine in injec- 
tions are very limited, and to produce the mydriatic effect, the form of instillation 
is preferable. Even when a full quantity is injected, the dilatation of the 
pupils is moderate, and the power of accommodation of the iris is not superseded, 
wMlst the desired effect is obtained by much smaller doses introduced between 
the eyelids. In neuralgia, iniections of atropine do no good, in spasmodic 
affections their effect is very doubtful ; so that their employment seems to be 
limited to cases in which the conjunctiva would not tolerate the presence of 
the atropine. — BuUelin GiiUral de TkSrapeutique, 

ON ▲ NEW MODE OF APPLYING SOME EXTERNAL AGENTS TO THE EYE. 
BY J. F. STREATFIELD, F.E.C.8. 

The use of paper as a medium for the anplication of sulphate of atropine and 
yarious other soluble salts to the eye, nas been before the public since my 
communication on the subject in the " Ophthalmic Hospital Keports,*^ in the 
number for January 1862. This medium has been very much approved, and, 
I may say, generaUy adopted, owing to its convenience, and more or less also 



V 



ISM.] 



8UBGEBT. 68 



owing to its peculiar efficacy in some cases. It has occurred to me that an 
improvement might be made if, in the new medium we could secure, along with 
the convenience and efficacy pertaining to the paper, some vehicle which 
would not need to be removed from the eye after it had been applied, and the 
desired result had been ^ined. I have not now time or space even briefly to 
relate the advantages arising from, or the way of making the application by, 
the paper vehicle. I can only refer to my communication above mentioned, 
and to another in the succeeding number of the same loumal. But I may 
aUnde to the alarm felt by some patients at any investigation of their eyes, 
even if only to remove the scrap of paper that has been introduced, and to the 
trouble sometimes found in removing it when it has got up beneath the upper 
lid. As the proposed substitute for paper need not be removed, the surgeon 
will often be saved a delay of twenty minutes, and will not be obliged to wait 
for the desired effect in order to remove the scrap of paper, and therefore, also, 
the patient can be trusted to employ the new medium himself, which is not the 
case with the old one. In order to obtain what I wanted, I first tried what is 
called " wafer paper," but this is brittle when dry, and looses all consistence 
when wet, so that it becomes unmanageable as soon as it is moistened ; and, 
moreover, the pulpy substance in the eye, if not washed out, might irritate. I 
am now employing gelatine, rolled out m sheets of the thickness of thin writing 
paper, and imbued with a definite proportion of sulphate of atropine or any 
other salt required. This retains the advantages of, and only requires the 
same mode of application as, atropine paper, but U need not be removed from the 
eye. It is soon aissolved in the tears, and acts in every way well. The dose 
employed thus, it appears, is more quickly applied to the eye than when a 
similar dose has to be dissolved out of the meshes of tissue paper; and to this 
it is that I attribute the pain felt by some of my patients when I have used a 
laige square of " gelatine atropine paper." They have not complained of pain 
when I have used a smaller bit (or dose), less than a whole square. 1 am 
thinking of having a check of small squares printed in green on the gelatine, 
to define the doses, and to make the transparent gelatine more readily visible 
when about to be uaed^ for it need not be looked for afterwards. It is made by 
Mr Squire, chemist to Her Majesty, 277 Oxford Street, London. — British ami 
Foreign Medico- Chirurgioal Review y let January 1864. 

ON A NEW AGENT FOB PRODUCING CONTRACTION OF THE PUPIL. 

We observe in a late number of the Prager Medizinische Wochenechrift^ that 
Dr Braidwood, a graduate of Edinburgh University, read before the Medical 
Society of Prague, a paper, embodying the results of a series of experiments 
upon the action of a new arrow poison from the island of Borneo, called 
'* dagakoch," a quantity of which he had obtained through the kindness of 
Professor Du Bois-Raymond. This substance acts both upon the heart and 
the pupils. Its effect upon the former is that of arresting its action, which 
it does by first causing weakness and irregularity in the cardiac contractions. 
Mid in a very short time their complete cessation. On post-mortem examina- 
tion the ventricles are found to be pale, bloodless, and contracted, while the 
auricles and veins are distended with blood. This substance acts upon the 
pupil in the same manner, though not so powerfully as the Cahibar bean, givmg 
rise to well-marked contraction. 

[We have received Dr Braidwood's paper, and shall insert it in the next Damber of this 
Jonmal.— Ed. Mbd. Jodbxal.] 



64 MEU)ICAL NEWS. [JULT 

yort iFottvt|. 



MEDICAL NEWS. 
MEDICOCraRURGICAL SOCIETY OP EDINBURGH. 

8E88ION XLm.— MEETING YD. 

Wedfuadayf 4ih May 1864.— Dr Douglas Maclagan, President of the 
Society, in the Chair. 

I. CIRRHOSIS OF THE LIVER. 

Dr Hdldane showed a specimen of cirrhosis of the liver^ which contained 
masses of syphilitic deposit. The particulars of the case will be fowid at 
p. 1074 of the last number of this Journal. 

II. EXOSTOSIS OF THE HUMERUS. 

Mr Spence showed the cast of the arm and a tumour which he had recently 
removed from the humerus of a boy twelve years of afe. The boy was an 
inmate of Ueriot^s Hospital, and was placed under Mr Spencers care by 
Dr Andrew Wood. It was stated that the swelling had oxuy been noticed 
a fortnight nreviously ; and the father of the patient said that his son had 
been carefully examined three months before, and nothing wrong had been 
noticed about the arm. From the feeling of the swelling, its hardness and 
firmness; from the fact of its having a distinct neck; and from the age 
and healthy appearance of the patient, Mr Spence came to the conclusion 
that the tumour was not of a malignant character, as from the rapidity of 
its growth one might have been led to believe, but that it was either an 
enchondroma or an exostosis, consisting partly of cartilage. The rapidity 
of the growth might probably be expleiiued by the youth of the patient 
and the activity with which all nutritive changes go on at that perioo. Mr 
Spence, accordmgly, determined to remove the tumour, reserving to himself 
the alternative, in the case that in the course of the operation the growth 
should turn out of a worse character than was anticipatea, of amputating the 
arm. A free longitudinal incision was made, and the growth was round deeply 
seated, partly below the deltoid, partly below the triceps muscle. It was 
removed readily enough, though the neck was found to oe broader than is 
usual in such cases. From the condition of the bursa over the tumour, as well 
as from the appearance of the tumour externally, and after being cut into, 
there could be uttle doubt that it was of a simple nature, in fact, an exostosis. 
Mr Spence had requested Dr Grainger Stewart to examine it microscopically, 
and had received from him the following note of the appearances found : — 

** The tumour consisted of a base or centre of spongy bone, with numerous 
cartilaginous nodules on its surface. These nodules were of various sices, 
and idl were connected with and passed into the bone. 

" Microscopically the bone presented its ordinary appearance, with corpuscles, 
canaHculi, etc. (fig. 1). The cartilage presented three distinct varieties. 

"1. In some parts it presented the ordinary appearance of costal cartilage. 

" 2. In some its cells were greatly enlarged, and rapidly proliferating, com- 
paratively little intercellular substance remaining, and that presenting a some- 
what fibrous character. This form seemed to be most abundant where the 
greatest elevations existed, i.e, where there was most rapid growth. (Fig. 2). 

*^ 3. In some parts the cartilage was impregnated with calcareous matter, or 
was passing into bone. In these parts the cartilage cells was of considerable 
size, and contained distinct rounded nuclei, which sent out processes, and 



1864.] MEDICO-OHIRUBOICAL SOCIETY OF EDINBURGH. 65 

became jagged as they approached the line of OMification — ^they presented the 
appearance of bone corpuscles — and it seemed to me that they became trans- 
formed into them. The deposit of the salts of lime first appeared in the inter- 
cellular substance, and most markedly in the walls of the cartilage cells, and 
gradually spread into the cell contents, and defined the bone corpuscles. 

^ In the fibrous and muscular tissues connected with the tumour, I found 
many of the nuclei enlarged, but not to any extent beyond what might be 
accounted for by simple irritation." 

Perhaps the most interesting point in this case was the rapidity with which 
the tumour had formed ; now, though this might doubtless be in piirt explained 
by the youth of the patient, Mr Spence was inclined to believe that the tumour, 
for a long time, had been simply overlooked. We knew that this was fre- 
quently the case with regard to exostoses of the femur, and that these might 
attain a considerable size without the attention of the patient being directed 
to them. And as the rapiditj of growth was the only suspicious circumstance 
in this case, Mr Spence was mclined to explain it in this way, and would fain 
hope that what he had removed was a simple tumour of bone, and that there 
was no danger of its recurrence. 

III. OVARIAN TUMOURS REMOVED BY OVARIOTOMY. 

Dr Thomas Keiih showed six ovarian tumours which he had recently removed 
by ovariotomy. With a single exception all of these were examples of the 
common multilocular growths ; in the exceptional case the tumour consisted of a 
single cyst. Of these patients five had recovered, one died. The case where 
death occurred went wrong almost immediately after the operation, fatal 
peritonitis bavins set in. The patients were of various ages, from twenty-one 
to sixty-eight ; the latter age being, so far as Dr Keith knew, the greatest at 
which the operation had been performed; the patient had gone on well. 
The last operation had been performed in the case of a woman of twenty-one 
on the 29th of April ; the lower part of the tumour was nearly solid, and there 
had been great difficulty in the aiagnosis, as it had been almost impossible to 
determine the state of the uterus. In the course of the operation the solid 
portion of the tumour was found to fill up the pelvic cavity; the patient 
had been exceedingly feeble at the time, but had since gone on remarkably 
well. In conclusion, Dr Keith might state that he had performed ovario- 
tomy fourteen times ; that ten of the patients had recovered, and that four 
had died. 

IV. DISEASE OF LOWER END OF FEMUR. 

Dr Wataon showed the lower part of the femur and the upper part of the 
tibia, from a case in which he had recently performed amputation. The dis- 
ease had continued for eighteen months, and had been attended by extensive 
and copious suppuration. The articulating ends of the bones were completely 
honeycombed, tne proximate ends of the shafts much thickened, and the 
epiphysis of the femur had been displaced completely inwards and backwards 
by the softening process which had affected the bone, more especially at the 
junction of the shaft with the epiphysis. 

V. FRACTURE OF NECK OF SCAPULA. 

Dr WaUon showed a specimen of fracture of the neck of the scapula, com- 
plicated by fracture of the neck of the humerus and ribs, with laceration of 
the axillary artery. . The injury was the result of direct violence applied to 
the shoulaers. 

VI. TUMOUR OF HARD PALATE. 

Dr Wataon exhibited a tumour occupying and developed from the hard 
p^te ui)on the right side, which he had recently removed from a patient of 
th Mackie^s of Cupar. The operation was effected through an incision dividing 
the centre of the upper lip. The bone was divided in the middle line by bone 
pliers, and by a transverse section of the upper jaw by the saw. The palatal 

VOL. X.— NO. I. I 



66 MEDICAL NEWS. [JULT 

Elate and alveolar arch were then easily removed, leaving the palatal bone 
ehind soond and intact. 

VII. ANNULAR SEQUESTRUM FROM TIBIA. 

Dr Watson shoyred a sequestruro from the tibia, in shape like a tailor *8 thimble; 
it formed the parietes of a trephine incision, which he had made some months 
ago, for the purpose of openmg an abscess cavity in the bone, in order to 
extract a small sequestrum. 

VIII. SUCCESSFUL PRIMARY AMPUTATION AT THE HIP-JOINT. 

Mr Spence read a paper on this subject, which will be found at page 1 of 
this number of the Journal. 

Professor Miller had listened with much, interest to the details of this case. 
He was inclined to attribute the patient's recovery chiefly to two circumstances. 
In the first place, the patient nad been treated on the spot, and had con- 
sequently been spared a long and painful transit ; in this way, as Mr Spence 
had remarked, there was scarcely any secondary shock to be gone through. 
In the second place, infinite credit was due to Mr Spence and to his assistants 
for the mode in which the operation had been performed ; very little blood had 
been lost — a most important point in a young subject. These Mr Miller con- 
sidered the two main causes of the successful issue of the case. At the same 
time, Mr Miller would not put out of sight the locality where the operation 
had been performed, and the after-treatment conducted ; for, circumscribed as 
the space of the patient's lodging was, he was at least as fairly situated in this 
respect as if he nad been in a hospital. With Mr Spence's conclusions Pro- 
fessor Miller quite agreed ; and he must say that he considered that Scottish 
surgery was entitled to no little credit for the successful termination of this 
case. 

IX. GANGRENE FROM OBSTRUCTION OF THE COMMON ILIAC ARTERY. 

Mr Spence read a paper containing the particulars of a remarkable case of 
plugging of the right common Uiac artery, which will be found at page 7 of 
the present number of this Journal. 

Professor Simpson had formerly brought before the Society a series of cases 
of obstruction of arteries, but no one of them had been exactly of this type ; 
in fact, he believed that the case now related by Mr Spence was in some 
respects unique. So far, however, as he understood Mr Spence's explanation, 
he considered it somewhat forced. It seemed to be this: the artery haa 
become obstructed by a coagulum, which had formed in consequence of the 
diseased condition of its coats ; the circulation was for a time arrested ; blood, 
however, in course of time oozed through, and the interior and perhaps the 
middle coat of the artery was dissected from the outer. Mr Spence seemed to 
think that the direction of the dissection should have been doumwards — that 
is, in the course of the circulation. This, however, in Dr Simpson's opinion, 
must depend upon whether there was more facility for the blood to get up or 
down ; for, when the blood once got out, the law of fluid pressure came mto 
operation, — that is to say, the pressure was equal in all directions, — and if 
there was less resistance to pressure upwards than downwards, the blood 
would obey that law and spread upward. Dr Simpson believed that dissecting 
aneurisms generally were not to be accounted for by the direction of the stream 
of blood, but by the facility with which the blood burrowed in one or other 
direction. One symptom to which Mr Spence had alluded was the pain 
experienced by the patient. Of this Dr Simpson had seen several marked 
instances ; in one case, in particular, it had been so intense that the patient on 
various occasions required to have chloroform administered for hours together, 
as without it her screaming was quite unbearable. The pain in these cases 
was a common but not easily explicable symptom. 

Profes9or Madagan might mention a case as illustrative of Professor Simp- 
son's remarks in r^ard to the frequency of pain as a symptom of obstract^d 
arteries. In September last, he saw a gentleman who bad just returned from 
country quarters, where he had suffered from what appeared to be sdatka. 



1864.] MEDICO-CHIRURQICAL SOCIETY OF EDINBUBOH. 67 

aod for wbich he hftd undergone appropriate treatment. When aeen by Dr 
Madagan, he was found to be subject to severe paroxysms of pain running 
down toe back of the thigh and leg as &r as to the foot. On exammation, there 
was found to be a little diminution in the warmth of the foot, and the patient 
described it as feeling '* asleep." No pnlse could be felt in the posterior tibial 
artery; and Dr Madasan came to the conclusion that the case was one ot 
embolism of the femoru artery. Dr George Keith, who also saw the patient 
at that time, was of the same opinion. For the next three months the gentle- 
man was able to go about ana attend to his business. Three months after- 
wards, the patient had an unusually severe paroxysm of pain, which occurred 
while getting out of bed ; next day a little gan^p-enous spot was noticed on the 
foot Dr liuiclagan altered the treatment which had been hitherto pursued. 
The limb was wrapped up in cotton wadding, and antiphlogistic means were 
employed. Professor Svme saw the patient, but did not recommend any 
further interference. There was an appearance of the formation of a line of 
demarcation, but it never came to anytnmg. A slight gangrenous appearance 
of the other limb manifested itself, and the patient gradually sank. It should 
also be stated that, in the interval between the time when Dr Maclacan first 
saw the patient and the occurrence of the gangrene, the patient had a very 
slight hemlplegic attack ; there was a little twistmg of the face, and a degree 
of thickness of articulation. This attack in all probability depended upon 
embolism of one of the cerebral arteries. The heart was frequently examined, 
but nothing abnormal was detected. 

Mr Spence thought there was very little difference between his own explana- 
tion of the formation of the dissecting aneurism and that suggested by Dr 
Simpson, so far as the law of fluid pressure was concerned. He had specially 
referred to tlie direction of the separation of the arterial coats, as showmg that 
the dissecting aneurism was probably not the primary cause of the gangrene, 
but resulted from the force of the reflux current of^ blood acting on a weak 

S^int of the artery when its usual onward course had been previously obstructed, 
e would quote the words of his paper as showing this : — " The current of the 
excited circulation being obstructed beyond by the previous coagulation, caused 
the coats of the distended artery to yield at the diseased part, and the reflux cur- 
rent of the blood to force itself between the tissues of the artery, thus separating 
them in the backward direction towards the heart." With regard to the pain 
which had been experienced, this was met with in almost all cases of aneurism, 
and after the appbcation of a ligature. The usual explanation was, that when 
the main artery was obstructed, the collateral vessels became enlarged ; the 
•mall veeseb and the neiuilemmal branches shared in this process ; hewse there 
was pressure upon the nerve-substance, and this occasioned the pain. 

Profeuor ^npiou did not think Mr Spence*s explanation of the cause of 
pain m these cases satisfactory. When perchloride of iron was injected into 
the sac of an aneurism, and coagulated the blood there and in the afierent 
artery, sometimes the pain had proved instantaneous and extreme, occurring 
long before any chanse could take place in the collateral vessels. In cases of 
obstructed arteries also, the pain often went off for a long time, and again 
came on. It was stated that in one of the first cases on record, that extreme 
pain was experienced in the lower extremity ; the patient was seen in consulta- 
tion by several Parisian doctors, who doubted of what nature it was, whether 
rheumatic, neuralgic, etc. Her physician Dr Le^roux, found, however, on 
careful examination, that there was no arterial pulsation in the foot and left, 
and came to the conclusion that the main artery nad become obstructed, whidi 
was corroborated on dissection. The occurrence of pain led to this almost 
accidentid discovery of the obstruction. 

Mr Spence did not think it surprising that the perchloride of iron should 
cause great pain when injected into the sac of an aneurism, for it did so when- 
ever it was applied to a raw surface. The perchloride was sometimes injected 
in cases of nsevus, and then also it caused great pain. 

JDr P, H. Wateon thought it was certainly remarkable that pain in embolism 
shoald not merely be on the distal side of the obstruction, but that it should 



68 MEDICAL NEWS. [jULY 

be felt at the point. Hitherto it had never been supposed that the arterial 
tissue was very sensitive, and there must be some unknown cause to account 
for the suffering. He quite agreed with Mr Spence that injecting perchloride 
of iron into a nsBvus caused severe pain. 

Professor Laycock had observed closelv several cases which were somewhat 
similar to that which had been described by Dr Maclagan. In particular, he 
remembered the case of a gentleman, a solicitor, who had been much engrossed 
with writing. In consequence apparently of excessive use of the right hand and 
arm, he began to suffer from neuralgic pains in them. The arm and hand got 
red ; spots of a redder and deeper colour made their appearance ; finally the 
parts became cold, and arterial pulsation was found to have ceased. The 
patient went to London and consulted several surgeons, among others the late 
Sir Benjamin Brodie. Some diagnosed an aneurism, others, an obstruction of 
the artery. A certain amount of gangrene took place, and the patient lost the 
tips of his fingers. The patient tonen came under Dr Laycock*s care, and was 
under observation for some months. He suffered from repeated paroxysms of 
pain, and at these times the arm and hand were studded with deep red spots 
which were the seats of such exquisite agony, that large quantities of opium 
required to be administered. Dr Laycock was finally led to the conclusion 
that the pain did not depend upon obstruction of the vessels, but that it was of 
a nervous character, and that it preceded or coincided with the morbid condi- 
tion of the vessels. Another important point in the case was, that the patient 
had neuralgic pains over the liver, and that when these were present, Bpots 
similar to those on the limbs made their appearance in that situation. The 
patient recovered a fair state of health, but was unfit for his profession, and 
accordingly determined to enter the church. In consequence apparently of 
having walked too much, he had an attack of neuralgia of the right leg ; the 
nervous system appeared to be exclusively affected ; there was at wnt no 
appearance of embolism. In the course of a day or two, however, the artery 
became obstructed, and the patient lost two or three of his toes. He recovered 
from this attack, and subsequently tried various means for the relief of the 
neuralgia which affected his head, scalp, shoulders, and other parts. Finally 
there was vomiting of blood ; the spleen was found enlarged ; dropsy super- 
vened, and death soon followed. This patient appeared to be powerfully pre- 
disposed to disease of the bloodvessels ; his uncle at the age of twenty -two 
haa lost a limb from the same cause ; he had overwalked himself; an obstruc- 
tion of the artery took place ; gangrene set in, and he died. In neither case 
was there any reason to believe that there was any atheroma of the vessels to 
predispose to this obstruction. Dr Laycock, indeed, was satisfied that there 
was not, but considered that a change in the nervous system preceded the 
morbid condition of the artery ; pluggmg occurred, but the neuralgia preceded 
or coincided with its occurrence. 

Dr Haldane would state what he believed to be the cause of pain in cases of 
obstruction of the arteries. In the normal condition, there was no conscious 
sensation in the arterial coats. The same was true with regard to the intes- 
tinal canal ; in a healthy condition we were not conscious of the presence of 
matters in the bowels ; but if the intestines became distended witti air, or if 
they were spasmodically contracted, severe pain was the result. The structure 
of the arteries was essentially the same as tnat of the intestines ; in each case 
the middle coat consisted of involuntary muscular fibre. The external coat of 
the arteries was abundantly supplied with nerves ; any abnormal contraction 
or dilatation of the middle coat would necessarily irritate these, and under 
these unnatural conditions, pain would result. The dilatation might be pro- 
duced by the presence of an obstructing clot, or the accumulation of blood 
behind it ; while the irritation of the inner coat of the vessel might lead to 
spasm and contraction in the neighbourhood, or at more distant points. 

Dr Sanders would hazard a suggestion as to the cause of the pain in these 
cases. If an artery was obstructed, the coUateral circulation coula not at once 
supply the necessary quantity of blood to the parts below. The result was, 
that a species of molecular death was going on for a time ; such changes took 



1864.] OBSTETRICAL 80CIETT OF EDINBURGH. 69 

place in the nerres as would lead to the Mine reault as if the nerre had been 
injared. By the molecular disintegration of the particles, the whole fibres were 
irritated, and the irritation was applied exactly where it would be most powerful 
— that is, at and near the sensory extremities. 

Fro/ester Simp&an remarked that there was this difficulty in accepting Dr 
Sanders' explanation of the pain in cases of embolism, that severe pain did not 
follow the application of a ligature to an artery ; in such a case, tne interrup- 
tion of the flow of blood was sudden and complete, and the causes to which Dr 
Sanders had aUuded ought to be in full operation. On the whole, Dr Simpson 
was inclined to attach a good deal of weight to the explanation suggestea by 
Dr Haldane. 

PROCEEDINGS OF THE EDINBURGH OBSTETRICAL SOCIETY. 

SESSION XXIII.— MEETING Y. 

21th January 1864.— Dr Graham Weir, PreMeni, in the Chauri 

' I. CASE OF RENAL CALCULUS IN A CHILD. 

Dr Graham Weir gave the following history of this case : — 

Samuel Johnston, age 3 years, admitted to the Edinburgh Hospital for Sick 
Children on the 20th of Februaiy 1862. 

History before Admisnan, — ^His father says that when bom he was a stout, 
healthy child, and that when six weeks old he became suddenly sick and ill, and 
began to swell about the lower part of the abdomen, especially about the 
scrotum, which latter increased rapidly, and to such an extent as almost to 
entirely conceal the penis. In this condition he remained for upwards of a 
week, and then began gradnally^ to recover. About this time his thirst 
became, and continued up to within a .short time of his admission to the 
hospital, almost insatiable. His urine began to dribble away from him. When 
about a year old he was examined by a medical practitioner in attendance 
apparently for stone. There was never any blood noticed in the urine, and 
though frequently complaining of sickness, and inclined to keep his bed for a 
few da^s at such times, he never complained of pain either in kidneys, bladder, 
or perns. 

Symptanu on Admisdon, — Patient is a thin, emaciated child, with a very 
sallow complexion, and looks much older than he is said to be. Complains of 
no pain. At times, and esnecially when he is going about the wards, he has 
complete control over the bladder, and is able to retam his urine for a consid- 
erable time, and pass it in a tolerably full stream ; but when in bed this control 
is lost, and his urine dribbles continually from him. 

The urine is of a dark, smoky hue, which, on cooling, deposits a thick white 
sediment. On the application of heat and nitric acid, albumen is thrown down 
in large quantities ; and, on examination by the microscope, this white sediment 
is found to be composed entirely of pus-corpuscles. Alter having been in the 
hospital for a fortnight his general health improved, and it was frequently 
remarked how happy and contented he always was, never complaining of pain 
or uneasiness of any kind. In this condition he continued up to Sunday, 30th 
March, when he began to complain of sickness, with loss of appetite, a slight 
dusky-brown rash at the same time showing itself about the nates. On the 
following day, he became feverish, tongue red, dry, and somewhat glazed; 
pulse weak, and about 140; considerable swelling externally on each side of 
the throat, and a mixed kind of rash was observed over the greater part of the 
body. The uvula and tonsils were also inflamed and swollen, but not ulcer- 
atea. This rash continued for three or four days, and then disappeared, as did 
also the affection of the throat. He never completely rallied from this attack, 
but continued to grow weaker until the 23d of April, when he died. 

Inspection, — External appearance, that of the last stage of marasmus. The 
thoracic and abdominal cavities were alone examined, and, with the exception 
of the kidneys, their contents were healthy. 



70 MEDICAL NEWS. [jULY 

Both kidneys were deeply lobulated, and double the normal size. A section 
of the right kidney being made, the pelvis was found greatly enlarged, and 
completely filled by the calculus marked 1 in the woodcut. No. 3 was also 
found in this kidney, but in a cyst detached from No. 1. 

The caloulus marked No. 2 was found m the pelvis of the left kidney. 




I am indebted to Dr Arthur Gamgee for the following accurate description 
uid carefid chemical analysis of the calculi. 

** Calculus No. 1, the largest, consists of a trian^ar body, with four pro- 
cesses projecting from its bue. The largest and thickest of these processes ia 
situated at one extremity of the base, and is capped by a very white calcareous- 
lookine mass. The process at the other extremity of the base is bifurcated. 
Tlie calculus as a whole is like an ill-shaped hand with out-spread fingers. 

The body of the calculus is of a pale fawn colour ; the processes, especially 
ttt their summits, are white. 

Weight of calculus, 94-17 grains. Measurements — ^greatest length, 1 inch 6 
lines ; length, 1 inch ; breadth, 1 inch 6 lines. 

Chemical Composition. — Portions of the body of the calculus and the white 
masses were subjected to analysis ; the body of the calculus consists mainly of 
the phosphate of magnesia and ammonia (triple phosphate), with a very httle 
phosphate of lime, and a considerable quantity of organic matter. 

The fawn-coloured superficial layer was specially tested for uric acid and 
urate of ammonia, but none was found. 

Calculus 2. — ^Thifl calculus ia of a very irregular shape, and is composed of 
two masses, of which the convexity of the one fits into the concavity of the 
other. These masses were so slightly connected, that in scraping a tew frag- 
ments off for chemical examination, they became detached. One of these 
portions of the calculus has projecting from it two processes, both of which 
are bifurcated, each being capped with masses exactly resembling those of 
calculus 1. 

Weight of calculus, 37*01 grains. Measurement, greatest length, H lines. 
This calculus has very evidently much the same structure as csJculus 1 ; its 
colour is, however, different. Some portions of its surface are of a fawB 
colour, others are of a bluish purple, and others of a beautiful pink tint. Ab 
before stated, the processes of this cmlculus are like those of the first, capped 
with white masses. In this case the summit of the masses is finely tinged with 
pink colouring matter. 

Chemical Composition. — ^The quantity of oolonring matter is so small that 
its properties could not have been investigated without altogether destroying 
the calculus. By exclusion, however, I think we may safely say that theite 
colouring matters must be blue and red colouring matters (uroglaucine and 
wihodine) produced by the oxidation of indican in the urine. The tint 
exactly resembles these substances. 



1864.] 0B8TETB1GAL SOCIETY OF BDINBUBGH. 71 

The body of the caleolnfi eonflists of phosphate of lime, mixed with a rwy 
small quantity of the triple phosphate and organic matter. The eomposition 
of this calculus diifers from that of the first, in as far as in the latter there was 
much triple phosphate, with little phosphate of lime; in calculus 2, much 
phosphate of lime, with little triple phosphate. In neither case wa« the 
mixture such as to confer a fusible cnaracter to the concretions. 

The masses situated on the processes were so evidently the same as those 
in the same situation in calculus 1, that I did not examine them. 

Calculus 3. — ^This calculus is very small, is of an oral shape, and weighs 8'i 
grains. Its largest diameter measures 2) lines. 

Chemical Composition. — Same as body of calculus 2, and consists chiefly 
of phosphate of lime with a little triple phosphate. 

Dr Weir remarked that the case was mteresting on account of the large size 
and peculiar form of the calculus, as well as the immunity from pain. 

Dr Moir had met with a case in an adult where there were numerous calculi ; 
yet the patient had never complained of any pain, although his occupation, 
that of a dancing-master, might have been expected to have given rise to that 
symptom. 

Profeuor Sir/yMon explained that the paroxysms of pain caused by a renal 
calculus were due to the stone falling down into the ureter, and there acting as 
a plug or pea-valve, the fit lasting till it was removed. Acting upon this view, 
he had treated some such cases by elevating the pelvis of the patient above 
that of the rest of the body, so as to allow the plug to fall back and permit the 
urine to pass. He at one time had a patient under his care who suffered 
frequently in this manner. One day, havmg received a message that the ladj 
was in great agony, and had taken chloroform without relief, he sent his 
assistant, with directions to turn her over the back of a sofa with her head 
downwards. He soon returned, and with surprise exclaimed, " I have cared 
her I What have I done?'* The patient has been several times relieved in 
this manner. Pain could not occur in Dr Weirds case, because the calculus was 
held too high up to obstruct the flow of urine. 

n. INDENTATIONS ON THE UTERINE SURFACE OF THE PLACENTA. ' 

Frofeuoft Sitnpson showed a preparation, which he had seen some examples 
of without knowing its exact pathology. It was a case of placenta prsBvia. 
The histonr of it was as follows : — 

On the 24th of January last, at half-past four in the morning, Mrs W., on 
rising to make water, was seized with oleeding from the vagina. For soma 
years past she had lost much blood from piles ; she had bom three childnm. 
the labours being easy, with the exception of the first, when the forceps had 
to be used, and was now by her computation at the full time in her fourth 
pregnancy. At half^past ^ve^ when the first examination was made by Dr 
FinJuiy, a comer of the placenta was felt projecting behind the front lip of tiM 
OS uteri, and as the bleeding, though it had abated, did not cease, the mem- 
branes were raptured at a quarter from seven, when the head of the child was 
felt presenting. After this there was no more haemorrhage. Between ten and 
eleven in the forenoon slight labour-pains were felt, and recurred at intervals 
of half an hour, until two o'clock, when a hand of the child was felt jprojecUng 
into the vagina, and the head could be reached by the point of the nnger only 
with great difficulty. The pains went on as before, and at half-past five the 
ease was seen by Dr Simpson, who, shortly before seven, deliverea by turaing« 
the patient having been rendered insensible by the action of chloroform. 
The child was dead. No bleeding followed the operation, and Mrs W. passed 
a good night under the influence of opium. During the next two days she 
felt pretty well, but the pulse never fell below 120. On the third fi(ay sh« 
became delirious, the pulse rose to 160, and on the sixth dav she died. 

The site of the rupture of the bag shows the position of the placenta to have 
been over the os. The peculiarity of the case consisted in several deep indenta- 
tions <m the uterine suiace of the organ by clots of blood. The cause why snob 



72 MEDICAL NEWS. [jULT 

indentations shoold take place in some cases he was unable to explain to his own 
satisfaction. Were such indentations not the result of the compression of 
the comparatively yielding placental tissue b^ incarcerated and accumulating 
clots of blood ? One of the students in his class, to which he had put 
the question, supposed it due to the pressure of the head when passing the 
placenta. He (Prof. S.) had examined, with Dr Peddie, the body of a patient 
who had died in labour with very little bleeding, but where they found on 
dissection a large clot of blood lying on the centre of the placenta, which 
organ was attached high up in the uterus beyond the reach ot the head, and 
showed a very large and very deep depression or indentation at the site of the 
clot. Merriman and others relate some cases of the same kind. 

Dr Weir had met with such cases. 

Dr Moir thought that it occurred in cases of partial separation of the 
placenta, but where the blood did not escape on account of tnat organ being 
still attached or adherent round its edges. 



MEETING VI. 

1(WA Fdruary 1864.— Dr Pattison, Vtce-Prendent, in the Chair. 

I. ON AMPUTATION OF THE CEKYIX UTEKI IN CASES OF ELONGATION. 

Dr Alex, R, Simpson, in the absence of Professor Simpson, showed a draw- 
ing of a portion of the anterior lip of the cervix, which had been removed by 
the ^craseur. There had lately oeen a patient in the hospital on whom the 
same operation had been performed, and whose history was as follows : — 

Joan Campbell, aged 29, admitted to the Royal Infirmary, November 26, 1863. 

About six and a half years ago, patient began to suffer from bearing^down 

Eiins. Six months previously she had eiven birth to a female child. The 
hour was difficult and tedious — the shoulder presented, and turning was 
resorted to. Ten months after the birth of the child, her doctor discovered 
that the cervix of the uterus protruded beyond the vulva. Some kind of 
instrument was introduced into the vagina, for the purpose of keeping the 
uterus in its position, — it having fallen down somewhat, — ^but was withdrawn 
two days subsequentlv in consequence of inflammation attacking the uterus. 



During the three following years patient suffered from repeated attacks of a 
similar nature. For five weeks after the birth of her child patient had a con- 
stant discharge of blood from the womb. Four weeks after tne bleeding ceased 
she menstruated, and continued to alter regularly everv month for about the 
space of one year. Although she had nursed her child for the ten months 
previous to the first inflammatory attack, it is worthy of notice that she men- 
struated regularly every month duruig that period. For the last five vears 
patient has menstruated every two or three weeks. During this period, and 
especially when '* poorly,'* she suffered from considerable pain in the right 
groin — so much so at times, that the weight of her clothes was unbearable. 

On admission, the general health was good. The uterus was somewhat pro- 
lapsed and the cervix elongated. 

On December 22, Professor Simpson pulled the cervix outside the labii, 
applied the ^craseur to the cervix, and amputated a portion about one inch in 
length. There was almost no bleeding. 

Patient slept well after the operation, and never had a bad symptom, with 
the exception that on the day after the operation she required to have the 
catheter passed, to draw off her water. She made a good recovery, and was 
dismissed cured on the 12th of January. 

The operation in these cases was performed by transfixing the portion to be 
removed by one or two long needles, and passing the cham of the ^craseur 
over above them. There was no hsemorrhage after the operation. 

Dr Thornaa Balfour had a patient under his care where the cervix was con- 
siderably enlarged. The patient was only sixteen years of age, and the pro- 
minent symptom was great menorrha^a. Under local astringents and general 



1864.] 0B8TETBICAJ. 80CIBTT OF EDINBURGH. 73 

tODicB the uenorrhagia had greatly decreased, bat the cervix remained in much 
the same condition. 

U. CASE OF PUERPERAL TETANUS. 

The following notes, by />. MaegreggcTy Esq., were commonicated by Dr 
M*Cowan:— 

Mrs R., SBt. 27, the wife of a boot-closer, and the mother of three childreo, 
miscarried when about three months gone with her fourth. 

She could assign no particular cause for it, unless it was due to lifting a 
heavy tub a day or two before. 

On the mommg of the 9th January (1864), she felt slight {^ains in the lower 
part of the abdomen — resembling labour pains, — and soon noticed that she was 
losinff blood from the vagina. 

Thmking that she was again " unwell,** and not pregnant at all, she paid no 
attention to the bleeding tmit day. But on the morning of the 10th, the pains, 
which were hitherto trifling, became more severe, and the haemorrhage increased, 
when several la^ clots, followed by a considerable quantit^r of fluid blood, 
were expelled. She now felt much relieved, as the pains diminished in severity 
as well as in frequency. 

Feeling so much better, she did not think it necessary to call in medical 
assistance till late on the night of the 10th, when she was getting faint and 
giddy ; for the hemorrhage still coutinned although the piuns had decreased 
since the raoniing. I was sent for about 10 p.m., when I found her very psJe 
and blanched, rulse very feeble, small and quick, and so weak that she could 
hardly turn in bed. Findmg also that she was still losing blood, I immediately 
applied cold-water cloths to the lower part of the abdomen, laid her head low, 
and got the temperature of the apartment lowered. After continuing the cold 
cloths a little time, the hnmorrhage somewhat abated, but did not cease entirely. 
I then plumed the vagina, ordered her a little wine at stated intervals, and 
perfect quietness; and left her for the night. Next day, the 11th, I saw her 
again, removed the plo^, and, the bleeding not recurring, I ordered the con- 
tinuance of the wine, with beef-tea. On the 12th, she seemed much better; 
no bleeding had recurred; colour was showing in the cheeks and lips. I 
ordered fifteen drops of the tinctura fer. mur. thrice daily, with nourishing diet. 

She continued to make steady progress till the 16th, and feeling much better 
that day, she got out of bed in the evening, — contrary to my advice, however, 
as I still thought her too weak to assume the erect posture. 

On the morning of the 17th, she felt some stiffness about the neck, but not 
sufficient to alarm her. She aeain got out of bed during the day, and remained 
up most of the evening. Whue partaking of food she remarked that she had 
some difficulty in swaUowing the solid part of it. During that night, however, 
she was awakened by diffictdty of breathing and severe spasmodic contractions 
of the muscles of the neck and the lower jaw, which compelled her to sit up in 
bed and get supported by pillows. About noon on the 18th, I was again sent 
for (I did not see her on the 17th), when I found her sitting in bed, bent 
forwards (she could not lean back), very alarmed and anxious looking, and her 
teeth so firmly clenched that she could not part them. She was quite conscious, 
and was able to answer questions put to her. I ordered hot poultices to the 
neck and lower jaw, with a mixture of sol. morph. mur., canab. indica, and 
chloric eth., internally. After a little time the poultices so far relieved her 
that she was able to separate her teeth somewhat : very little, however, — 
enough to admit the point of a teaspoon only. I endeavoured to administer a 
dose of the medicine as above, and did get it into the mouth ; but as soon as 
she attempted to swallow it, a severe spasmodic action of the muscles of the 
pharynx and larynx immediately followed, threatening suffocation. She sprang 
forwards with an expression of agony and terror, and seized the bedclothes for 
support. The suffering was so severe that she would not be persuaded to txy 
another drop. The same mixture was then ordered to be given by enema, 
with beef-tea and wine. She had tasted no food that day. The enema was 

VOL. X.— NO. I. K 



74 KEDICAL NEWei [JULT 

given, and repeated after a lapse of a couple of hours, with no apparent diminu- 
tion of the symptoms. As the poultices at least soothed her, they were 
continued that night. On the morning of the 19th, I found her no better ; but 
the strength diminished. She was stiU sitting up in bed supported by pillows ; 
for although there were no very urgent .symptoms of dyspncea, yet she could 
not suffer the recumbent position. The enemata of beer- tea and wine were 
continued at intervals, but soon began to be rejected. 

I was obliged to leave her then, but soon returned, prepared to give her 
chloroform by inhalation. I found, however, that she was sinking very 
rapidly, and already so weak, and bathed in cold clammy perspiration that it 
would be absurd to attempt it. She died at 6 p.m., two hours after my visit, 
without a struggle. 

The only thmg I now regret is, not having exhibited chloroform sooner, when 
there was a chance of doing good. 

Dr PatUson thought, from the account just read, that the abortion had not 
been expelled ; and the best treatment under the circumstances would have 
been, if possible, to have emptied the uterus, since that organ was evidently 
the source of irritation. 

III. CASES OF ARRESTED DEVELOPMENT OF THE 17TERUB. 

Dr Alex. R, Simpson showed a preparation of an imperfectly developed 
uterus, and made a communication, which will appeal in a future number of 
the Journal. 



MEETING vn. 
9iA March, 1864.— Dr Graham Weir, Preddant, in the Chaur. 

I. TANGLE-TENTS. 

Frofenor Simpson reminded the Society that a variety of substances had 
been used as tents, passed into the os and cervix uteri with the view of dilat- 
ing the canal, so as to get access to the interior of the uterus for diagnostic 
and therapeutic purposes. In olden times they had made use of the dried 
gentian root, which was described by Cooke in nis " Marrow of Surgery,** and 
by various other writers, as the best substance for this purpose. His friend, 
Dr Horatio Storrer of Boston, had a few years a^o proposed tents made of the 
bark of the slippery elm. What he (Prof. S.) naa long been in the habit of 
using, as they were all aware, was a piece of sponge, which was brought into 
the proper shape by dipping it in a solution of gum, compressing it into a 
conical form by a piece of wnip-cord wound round it, and then d^ing it in 
an oven. Dr Braithwaite had afterwards pointed out to him that the ^um was 
unnecessary, for if the sponge were compressed after being simply dipped in 
hot water, it retained its form on being dried, and all that was tnen needed 
was to dip it in a mixture of wax and lard, to make for it an external coating, 
to fiftcilitate its introduction into the uterine cavity. Latterly, Dr Sloan of Ayr 
has proposed as a substitute for compressed sponge the driea stems of the sea- 
tangle (Laminaria digikUa), which is thrown up in such abundance along all 
our coasts. In its dried and collapsed condition it could be cut or filed down 
to any shape and size, and when placed in water, or brought into contact with 
the fluids of the uterus, it would swell up to such a degree that a piece of tangle 
would expand in the course of a few hours to about three times its original 
thickness. For some time past he (Prof. Simpson) had used the tan&le-tents, 
and had found them to fulfil all the indications of a uterine tent so admirably, 
that he believed they would ultimately replace the sponge and other substances 
hitherto employed. He had brought with him some specimens of tangle-tents 
made by Krohne in London, that the Fellows might have an opportunity of 
seeing them ; and also some bougies for the male urethra, and for the 
lachrymal ducts, — for its application was not restricted to the uterus, but 
might come into play for the dilatation of any kind of constricted canal. The 
tangle did not perhaps distend to such an extent as the sponge, but it exerted 
much greater power of dilatation ; for whilst a piece of sponge, which on 
withdrawal seemed to be of the thickness of the thumb, was found to have 



18e4.] 0B8TETBICAL SOCIETY OF EDINBURGH. 75 

left a CAoal which would barely admit the little finger, the canal left on the 
remoral of a piece of tangle wa« always found to correspond throughout in 
measurement with the full size of the expanded tent. The tangle had a 
further advantage over the sponge in that it does not absorb — or form rather — 
those foetid fluias with which a sponge always seems to get charged when left 
long in the genital canals. The tangle-tent, moreover, was more easy of 
introduction, because of its greater soudity and stiffness ; and though some- 
times he had found a little trouble in introducing it in consequence of its 
becoming slippery whenever it got moistened, yet then he had succeeded in 
passing it with the aid of a pair of long dressing-forceps, or, better still, of 
an old porte-aiguille. Then the greater abundance and consequent cheapness 
of the tangle presented an additional advantage ; and if we wanted to be very 
economicu, the same tent might be used a second time after being simply 
dried, — a process that would be attended with much danger if we had to do 
with a piece of sponge that had once been impregnated with deleterious dis- 
charges. The tangle did not dilate quite so rapidly, perhaps, as the sponge ; 
but tne expansion was effected with sufficient speed for all ordinary purposes. 
He showea a tangle-tent expanded to about the thickness of a little nnger, 
which he had removed from a patient on his way to the meeting at eight 
o^dock, and which had been introduced in the forenoon. In its dry, undilated 
condition, it might have been about the thickness of a crow-qudl. On the 
whole, he thought that tangle-tents would come to replace the others in use, 
because they were, — 1st, cheaper in price; 2d, more easy of introduction; 
3(/, more potent as dilators ; and, 4M, cleanlier in their use. 

Dr Keuler remarked that he had lately been using the tangle-tents, and had 
found them answer the purpose admirably; he felt sure they would soon 
supersede the sponge-tents in common use. He found that after drying them 
the^.were useful a second time. There was a difficulty in introducmg them, 
which he had endeavoured to overcome hj the use ot a pair of long curved 
forceps, upon which, however, he was making some improvements, and would 
exhibit them at the next meeting of the Society. He had used tangle before 
as bougies, but it did not occur to him to dry it for the purpose of re- 
expansion. 

Lh A. R, Simpson bad found this kind of tents verjr apt to slip out. A 

Siece of sponge placed below them held them in position till they began to 
ilate, but probably a piece of worsted wound round the point would be suffi- 
cient to overcome the difficulty. 

Dr Graham Weir thought that one of the greatest advantages of the tangle 
over the sponge tents, and which had been referred to by Professor Simpson, 
was their equal dilatation.; the sponge, as every one knew, often did not dilate 
at the very part it was most required. 

Professor Simpson incidentally remarked that the use in Switzerland, durmg 
the seventeenth and eighteenth centuries, of sponge and sea-tangle in goitre 
had been much ridiculed by some physicians ; but the problem of the utility 
was at once solved when, above half a century ago, iodine was found to cure 
goitre, and sea-weeds were found to contain iodine. Dr Gillis has recorded 
that he had found the natives of South America, far inland, using what were 
called goitre-sticks, which were nothing but sea-tangle. It was remarkable 
how two nations at so great a distance should thus both discover the use of 
iodine in goitre. 

n. CASE OF P0LTPU8 UTERI, WITH PREPARATION. 

Dr T. A. O. BaXfowr gave the following history of this case : — 
The patient had suffered from bad health till menstruation was fully estab- 
lished. She afterwards suffered much from menorrhagia, losing at those times 
large quantities of clotted blood. She was given tonics and wine ; her health 
improved, but the menorrhagia continued. There was in her history an illus- 
tration of the effect of mental emotion over the functions of the body. She 
turned unwell on the SOth June, but the menses suddenly disappeared on the 
2d July — her marriage-day. She continued to suffer from menorrhagia till 



76 MEDICAL NEWS. [JULT 

the end of January last, when Dr Balfour wan suddenly called to her. He 
found her extremely exhausted, and fainting from loss of blood, over which 
ergot and other remedies had no effect. On making a vaginal examination, 
the polypus, which he showed, was felt protruding through the os. He re- 
moved it by the ^craseur, and since that tune there had been no return of the 
menorrhagia. He had had occasion again to examine the patient, three weeks 
after, and felt the stalk of the polypus still nnabsorbed. There was no history 
at any time of the expulsion ot the polypus. 

ni. CASE OF SUDDEN DEATH TEN DAYS AFTER LABOUR. 

Dr T. A, O. Balfour gave the following history of this case : — 
The patient, 26 years of age. was confined of her second child. The labour 
was natural, and she did well tor nine days. On the morning of the tenth day 
she was getting over the bed, when she seemed to fieiint, and suddenly died. She 
was extremely anaemic, and suffered from shortness of breath. At the post- 
mortem examination, the liver and heart were found to be fatty. This was the 
only cause of death that could be discovered. The wonder was that the death 
did not occur during the severe pains of labour. 

PtofesBor Simpson was inclined to regard the case as one of embolism. The 
history was exactly that of many cases which had been recorded, where a plug 
had been discovered in the pulmonary artery. The patient progresses favour- 
ably, till, upon some slight exertion, she suddenly falls back, dead. A plug in 
one of the large veins of the uterus gets disengaged, and is carried on by the 
current of the circulation till arrested in the puunonary artery. 



REPORT OF THE TRIAL OP GEORGE BRYCE FOR MURDER, 
High Court of Justiciary, Edinburgh, dOiA and 31^ May 1864. 
With Remarks by Hugh Cowan, Advocate. 
In this trial the defence of insanity, although urged with great ingenuity and 
earnestness, was disregarded by the jury, who, after a lengthened trial, returned 
a verdict of guilty, coupled with a recommendation to mercy on account of the 
low mental organization of the prisoner. The grounds upon which the plea of 
insanity was in this case rested appear to me to be of a very inconclusive 
nature. The medical witnesses for the defence both founded strongly upon the 
opinion they had formed that the prisoner was a person of low mental oigani- 
zation, and they based then: opinion of his being at the time of the murder 
insane, upon the alleged delusion under which he was said to labour, that the 
person whom he murdered had at one time called him a drunken blackguard. 
Their opinion, they stated, was confirmed by the circumstance which they held 
to be proved that the prisoner had no recollection of his having done the deed. 
In regard to the first of these, it was well remarked by the Solicitor-General, 
in his speech to the jury, that it was just persons of low mental organisation 
that would commit murder, and who required to be restrained from committing 
it by the fear of punishment. As to the second, the medical gentlemen were 
both obliged to admit that, if it were true that the unfortunate deceased had 
called the prisoner a drunken blackguard, there would cease to be any delusion 
in the matter. The evidence on this point was conflicting, — it rather appeared 
that she had not said so to the prisoner, but it clearly appeared that she enter- 
tained this opinion regarding him, and that she had good reason for it. But, 
even if she had never said so, it would be a most serious matter for society if 
any man who, with or without foundation, conceives that another has miscalled 
him, should be allowed with impunity to cut that other's throat, and then say 
be had an insane delusion that the other called him a drunken blackguard. 
It is an utter mistake to say that this is such a delusion entering into the act 



1864.] TBIAL OF G£OKG£ BRTGE FOR UUBDEB. 77 

as will excuse a crime. To exempt from the ponishment of crime, the deln- 
sion must either be of such a nature that if it were not a delusion, but true, the 
man would be justified in acting as he is proved to have acted under the 
alleged delusion ; or it must be of such a nature as radically to change the 
whole character of the surrounding circumstances. Examples of such delusion 
may be found in the cases of Moyatos and Amot quoted below, where the man 
believed his own life to be in danger, or where a man believes himself to be a 
deity, or that it is a devil or a wild beast that he is attacking. Now« even 
admitting that Jeanie Seaton never called the prisoner a drunken blackguardy 
it was only a mistaken idea of the prisoner's that she did so. He was conscious 
in himself how deserved the appellation was, and it was this that made the 
unkind word rankle in his bosom. It was his unhappy hatred of this woman 
that wrought the change in the prisoner which was noticed ever after that 10th 
of March 1863 when he so behaved himself as to alienate the affections of 
Isabella Brown — Jeanie's neighbour. Rightly or wrongly, he took up the idea 
that Jeanie had something to do with this, and his heart conceived enmity 
against her. But it is only a man of a depraved and wicked moral nature, who 
could for so trifling an offence against him, if his idea in regard to her had been 
true, have conceived the deadly enmity and hatred which the prisoner did 
against Jeanie Seaton. No man whose mind is rightly constituted would have 
done the act committed by the prisoner. But what is it that makes the differ* 
ence between a murderer and other men ? Is it not just this, that while he 
allows the evil and wicked passions of his bad heart to obtain the mastery over 
him, and hurry him into crime, theff learn to control these evil passions and to 
cast them from them as abhorrent to the better nature which God has planted 
within them. A good man, imbued with Christian virtue, learns so far to over- 
come these bad feelings as even to love his enemies, and do good to those who 
hate him. But there are multitudes of bad men in the world who would 
willingly gratify their hatred of others by committing murder if it were not for 
a wholesome dread of its punishment. There seems to be only this distinction 
between their case and that of Bryce, that he was not deterred from wreaking 
his vengeance on his poor victim by this fear. And it will hardly recommend 
the plea of bsanity to the &vourable consideration of the uninitiated, if the 
only practical difference which insanity makes upon a man is that it frees him 
from the dread of punishment. That insanity does not really do so is well 
known to those who are engaged in the practical management of asylums, the 
inmates of which are capable not only of being deterred from what is against 
the rules by the fear of punishment, but of being induced to do what is right 
by the hope of reward. 

The alleged delusion in Bryce*s case comes then only to be an explanation 
of the motive of the crime. It would be curious and interesting to take a 
survey of the murders during the past half century and see how many of them 
were actuated by similar hatreds taken up from equally absurd grounds. It 
has been said that there can be no adequate motive for murder, and in a certain 
sense this is true, for whea the motive is adequate the act ceases to be a crime. 
We never can justify a murder, but we may often discover the motive which 
has impelled the murderer to his crime ; and when a motive to the commission 
of the crime is discovered in a case of doubtful evidence, it has hitherto been 
supposed only to furnish an explanation of the crime, and to add one to the 
other links in the chain of evidence against the prisoner. It was reserved for 
the ingenuity of the prisoner's counsel in this case, to turn the discovery of 



78 MEDICAL NEWS. [JULT 

the actuating motire, where the evidence without it was clear and conclusive, 
into a proof of the murderer*s insanity. The last circumstance founded on as 
showing the prisoner*s insanity is his total want of recollection of the crime. 
The circumstances tending to show that this was pretended are forcibly pointed 
out in the speech of the Lord Justice-General. It is difficult to believe that a 
man who recollects the minutest circumstances up to the moment of the com- 
mission of a crime can be speaking the truth when he says that from that point 
his memory is a blank. More especially u this difficult in a case where the 
crime is said to be committed under a delusion entering into the act. The 
analogy of other cases leads us to expect that the gratification of vengeance for 
the supposed wrong would fix the act on the man^s memory; and that it 
remained on this man*s memory is shown by the answer which he made to the 
policeman who charged him with the murder — She's cheap of what she's got — 
an observation which shows a dbtinct recollection of the deed which he had 
done. It is understood also that before his execution Bryce confessed that, in 
the statement that he had no recollection whatever of the murder, he was not 
speaking the truth. 

The plea of insanity in bar of trial has lately been stated in two cases— both 
trials for murder in the High Court of Justiciary. The one of these was the 
trial of Joannb Manolatos or Jean Moyatos, on 6th April last, for the murder, 
on board the British barque Pontiac, of Robert Campbell, a sailor dn board 
the same ship with him. He was also accused of a murderous assault on 
another sailor named George Williams. From the evidence it appeared that 
the prisoner laboured under the following insane delusion : — He had sailed from 
Liverpool in a vessel called the Atahualpa to Valparaiso, where it was wrecked. 
Shipping on board the Pontiac he sailed to Callao, where Campbell and 
Williams were shipped, and the Pontiac sailed for Liverpool. The delusion 
under which the prisoner laboured was that Campbell and Williams were hired 
by the captain of the Atahualpa to throw him overboard. Being possessed 
with this idea, which was proved to have no foundation in fact, he attacked 
the two sailors with his knife, causing the death of one, and seriously injuring 
the other. The other trial was that of Thomas Amot, on 6th June laist, for 
the murder of David Paton, a little boy, on the Stirling road, near Alloa. The 
prisoner was proved to be labouring under various delusions, the principal of 
which was that he was the subject of unremitting persecution on the part of 
the Free Church, and that the boy, whom he had never seen before, and against 
whom he had no enmity, was an emissary of the church — that he felt himself 
impelled to strike an unexpected blow against his enemies, and so killed the 
boy as a part of the general system. In this case the Lord Justice-General 
intimated that the Court had no difficulty in holding the insanity proved. 
Now, in both of these cases there was delusion entering into the act charged. 
In the one there was a delusion which might be said to justify the act of the 
prisoner. He was in bodily fear. His life was m danger, and he acted in self- 
defence. In the other there was a pervading delusion of such a nature as 
altered the whole circumstances about him so thoroughly that it is impossible 
for a sane man to imagine under what delusive idea at the moment the man 
acted. Both cases afford an instructive contrast to the case of Bryce, showing 
what the delusions are which the law regards as proof of insanity. 

The prisoner George Bryce was placed at the bar charged with the crime of 
murder, in so far as on Saturday the 16th day of April 1864, within the house 
or yilla, near the village of Ratho, occupied by Robert Tod, mill-master and 



1864.] TRIAL OF GEORGE BRTCE FOR MURDER. 79 

grain-roerchant, he did, wickedly and feloniously, attack and assault Jane 
Watt or Jane Seaton, now deceaaed, then a servant of the said Robert Tod, 
and did violently take hold of her and force her down, and get above her, and 
press upon her, and seize her by the throat, and did kick her, and otherwise 
maltreat and abuse her; and the said Jane Watt or Jane Seaton having fled 
from him, he did pursue her, and having overtaken her at a short distance from 
the foresaid house or villa, and near an old building called the Old Distillery, 
he did there wickedly and feloniously attack and assault the said Jane Watt 
or Jane Seaton, and did throw or knock her down, and did with a razor, or 
other sharp instrument, cut and wound her severely on or near the neck, by all 
which the said Jane Watt or Jane Seaton was mortally wounded and injured, 
and in consequence inmiediately or soon thereafter died, and was thus murdered 
by him. 

The counsel for the Crown were the Solicitor- General (Young) and Mr 
Adam Gifford, advocate-depute; the counsel for the prisoner were Messrs 
Patrick Eraser and Charles Scott, advocates. 

On the motion of the counsel for the prisoner, and of consent of the Crown, 
the medical witnesses were allowed to remain in Court to hear the evidence 
adduced as to the facts of the case. The pannel pled generally not guilty, and 
specially that at the time when the alleged crime was committed he was insane 
and labouring under insane delusions. 

The general evidence led in support of the charge established the following 
circumstances:— On Friday night, the 15th of April, the prisoner, who had 
not slept at home the night before, was put to bed by his father, being over- 
come either with drink or sleep.^ He rose about six on Saturday morning, and 
loitered about the yard at his father's house, which is in the village of Ratho, 
for nearly an hour.^ Leaving that about seven he crossed the bridge over the 
canal, going along the road past the villa occupied by Mr Tod.' To his uncle, 
who met him on the road, and asked where he was going, he replied, *^ To the 
station," the road being that which led to the railway station. He said to a 
baker's boy, whom he passed on the road, .after passing Mr Tod's gate, 
" Fine morning, batchie."' Leaping the wall of the villa he accosted Isabella 
Brown, who was at the back door, asking her where was Jeanie.^ Getting no 
answer he went in at the back door and found his way to the nursery, where 
he found the deceased and immediately attacked her, throwing her down and 
struggling with her.' She was rescued by her mistress, who called to her to 
run away. She did so but the prisoner followed, leaping the wall which sepa- 
rated the villa from the road, and having overtaken her he again threw her 
down, placing his knees upon her breast, and with a razor, which he had, cut 
her throat.^ The deceased was carried into a neighbouring house and laid on a 
mattress on the floor. The wound in her throat was bleeding dreadfully, but 
ahe asked for a drink of water ; but, when it was brought, she was unable to 
drink it, and she never spoke again, dying almost immediately.^ The prisoner, 
on leaving the deceased, endeavoured to make his escape, but was followed 

1 John Bryoe, his fkther. > John Weston, his nncle. * Adam Lawrie^ ^ Isabella Brovn. 

B Isabella Brown, Mrs Tod, Catherine Binnie, and Margaret Gibson. 

* John Yoang, Mrs Henderson, Mrs Binnie. 

7 The wonnd is thus described in the medical report prepared b7 Dr Littleiohn and Dr Cr^g :— 
There was a deep gash on the left side of the neck, about its middle, of an elliptical shape, measuring 
Ihlly five inches in length; its greatest breadth was two inches ; and its depth was, at its maximum, 

three inches, but both behind and in fh>nt it became superficial There was an aperture, tally 

an inch long, in the external Jugular yein Both sides of the neck were carefml7 dissected, 

when it was ascertained that the Jueular vein was the onl7 important vessel wounded, and that the 
carotid of the left side, and the oesophagus, and the trachea had escaped ii\)ur7. 



80 MEDICAL NEWS. [jULY 

and Becuied. In the course of the chace he twice threatened to take his own 
life with the nusor, and he tried to nse it against those who followed him. 
When apprehended he was told that he had cut a woman's neck, to which he 
replied) She's cheap of what she's got ; adding, that "he would rather go to 
Edinburgh than Ratho, as he did not like to pass his father's house, and among 
the people of his acquaintance. In his judicial declaration, emitted a few hours 
after the murder, the prisoner stated that he remembered going to Mr Tod's 
house that morning, but that he did not recollect of seeing any person at the 
house except Isabella Brown ; that he had no recollection of seeing Jane Seaton, 
or of doing anything to her. He recognised his cap, which he had left in the 
nursery, when shown him, and also his racor ; but denied having had the razor 
with him when he went to Mr Tod's house.^ 

The only question involved in the case was in regard to the prisoner's 
sanity. The following is a full note of those parts of the evidence of each 
witness which bore upon this question .- — 

Mrs Tod, — I never saw the prisoner do anything or heard him say anything 
that led me to suppose he was insane. Croaa-examined bjf Mr Eraser. — ^I have 
never had any lengthened conversation with the prisoner. I have often met 
him on the road, and almost always nodded to him. He always returned my 
nod. I could not say whether he was a shy man or a sulky man. I fonned 
the impression that he was either the one or the other from his look and 
demeanour. He was always very obliging and was very quiet. About a year 
a^o I spoke to Jeanie Seaton about a notion he had got that she had called 
hun a arunken blackguard. I said, it seems Qeoree Bryce is very angry at 
you for having said he drinks ; you needn't be auaid, for if he says an ill 
word to you, you have onlv to tell me, and Mr Tod will put a stop to that. 
She gave a little smile ana said. The stranee thing is that I never said such 
a thing. When he gazed at me when I had hold of his wrist I cannot say he 
recognised me. He had a bold, brutal look. 

John Young^ ploughman, and Mrs Hendersoti, both of whom had known the 
prisoner, deponed, That thepr had never seen or heard him do or say anything 
which led them to regard him as insane or different from other people. 

James Mackay^ constable, in cross-examination,— Vtv&oji&c usea to be riotous 
at his father's house sometimes, but only riotous so &r as I knew. After some 
of these scenes in his &ther's house he used to say when he was sober that he 
had no recollection of what had taken place. It appeared to me that there was 
a sort of a " want" about him. To the Lord JiLsUce- (general, — He appeared to be 
sort of silly, easilv advised and easily led away. He was easily led to go and 
drink with comrades. I never saw him doing anything oiUrS when he was sober. 

Robert Davidson, blacksmith. — I am about the same age as the prisoner, and 
was at school with him. I was pretty intimate with him, both at school and 
since. I never saw or heard of anything in his conduct that would have led me 
to suppose that he was insane, nor was there any such notion about the place. 

Dr James Craig, Ratho. — ^I have known the prisoner all his life. I fre« 
quently saw him soing about doing his work ; but I was not aware, till the 
month of October last, that he was addicted to drink. I then saw him in the 
police-office, where he was violent. I never saw anything in his conduct to 
lead me to suppose that he was wrong in his mind, or I would have considered 
it my duty to mform his father and the authorities concerning it. At that 
time liis father called upon me regarding his son's habits, and the difficulty he 
had in managing him when he was the worse of drink. When I saw him in 
the police-office last October he was perfectly rational. I gave him advice 
about refraining from drink. After that occasion I saw him going about as 

1 It iB underatood that before his exeeatfon the prieoner ooci<iBSBed that he had earried the rasor 
with him for a fDrtnlght, with the riew of eommittlng the murder; that, haring failed to And an 
opportunity at night, he had gone when he knew Mr Tod waa from home; and that be was quite 
aware of having committed the murder on that morning. 



1664.] TUIAL OF GEOBGE BRTCE FOR MUBDER. 81 

Qstud, and I never was consulted professionally since then. I have never seen 
anything about him that would lead me to doubt his sanity. In the evidence 
to-day 1 have heard nothing that would lead roe to believe he was insane. 
Cros^-eoMmined, — I have spoken to the accused only twice. In October, when 
I saw him in the police-office, he was perfectly sober, although somewhat 
flushed. He said he did not recollect anvthing that had taken place in his 
&ther*s house, and I told him ffenerallv wnat had taken place. After [ had 
spoken to him of the danger he ran by drinking, and when I spoke of his 
mother, he began to cry. 1 saw him next morning m the police-office, when he 
still denied afl recollection of what he had done when in drink. I could not, 
however, reconcile myself that he was telling truth. After his apprehension I 
again saw him in the police-office, when he again exhibited a defect of memory. 
I asked him what he nad been about that morning, but he gave me no answer. 
I asked him if he had been at Mr Tod*s, but he denied having been there. He 
likewise denied having that morning seen either Mrs Tod or Jane Seaton. I 
believed that he was not then aware of her death. I then asked him if he 
recollected when he had last seen me, when he answered " Yesterday." At 
that time I had forgot that I had seen him on the previous day, but this 
brought to m^ recollection that I had passed him while driving along the road. 
I then asked if he remembered the aa vices I had given him in October last, 
and he said he did. I also asked him why he did not follow them, but he save 
no answer. I then asked him where he had been all morning, and he told me 
he had been in the plantation. His answers were quite rational, and my 
onestions were with the view of satisfyine mvself as to his state of mindf. 
Re-examined, — I perfectly satisfied myself tnat he was quite sober, and quite 
intelligible. I knew Jane Seaton perfectly well. 

DrlAtU^ohnj police surgeon. — I saw the prisoner on the day of the murder. 
He was quite sooer and rational. I asked him if he was aware that to kill 
another was a crime. He said he was. I also asked him if he knew people 
were punished for so doin^, and he nodded acquiescence. Mv object in puttmg 
these questions was to satisfy the Sheriff as to the state of the prisT)ner^s mind 
before ne was examined. I was satisfied that he was in his sound and sober 
senses. In the evidence to-day I have heard nothing stated which leads me 
to believe otherwise. Crose-examined, — I never saw him before that day, and 
I have not seen him since. My conclusion as to his soundness of mind was 
from the answers he gave to the questions put to him, and from watching his 
demeanour. 

WilUam Btfint!0,jun., joiner, Ratho. — Between seven and eight on the morn- 
ing on which Jane Seaton was killed, I saw the prisoner near the canal bridge. 
He asked me about a house we were erecting in Dr Fowler*s garden, and I gave 
him the desired information. He appeared to be ouite sober and rational. I 
parted with him to the north side of the bridge, and he went in the direction of 
Mr Tod*s villa. I heard of the murder about ten or fifteen minutes afterwards, 
when I went to my father^s house, and- 1 saw the dead body. I was present 
when the prisoner was brought in to see the body. I yrBB at school with the 
prisoner, and have known him ever since. There was nothing in his conduct 
when at school, or since, that led me to believe that he was insane. Such a 
thought never occurred to me. On the Saturday rooming of the rourder he 
had on his light shoes, and did not seem as if he was going to work. Crais- 
esoaminedby Mr Scott. — ^When we told him it was a photographic house we were 
erecting at Dr Fowler*s, he smiled. He was a man who seldom spoke much. 

The following witnesses were examined for the defence : — 

Jamee Wight, formerly constable in the Edinburgh Police at Ratho, and now 
market officer in Leith. — While at Hat ho I knew the prisoner well. I had 
occasion to notice his state of mind on various occasions, and my opinion is 
that he had a ** want." It showed itself when I said, ** It's a fine morning," 
when he would reply, " YouVe a funny ane." If you asked him a question, tie 
would go on with a few words, and then go off into anotlier subject, as if for- 
getting what he had been talking about. His talk was rambling, and in the 

VOL. X.— NO. I. L 



82 MEDICAL NEWS. [jULY 

course of one conversation he would refer to many subjects. On one occasion, 
in the back end of 1857, there were two of the late Lord Morton's footmen 
and a gamekeeper along with him, when one or other tapped him gently on 
the shoulder, and said he was wrong in some particular statement. Bryce 
then drew a clasp-knife from his pocket, and said he would stab any man who 
said he was wrong. Before that they had all been laughing. When he had 
the knife in his hand he seemed to be very wild. I went between the prisoner 
and the footmen, ordered him to give the knife to me, and took him home. 
He went home quite peaceably. I went with him to his father's house, when 
he went to bed without speaking to any one, although his father and mother 
were in the kitchen. He was perfectly sober. I told his father that if he did 
not keep a watch over him he would do something that he would repent of. I 
did not then suggest that he should be taken charge of. I saw the prisoner 
next day, and asked him what he meant by drawing a knife to stab anvbody. 
He denied all knowledge of it, and said I was " shamming with him," ana " fun- 
ning with him." He was sober. At that time I thought he was ** shamming " 
with me — that he was pretending not to remember. After that I asked several 

Seople about him, and they said he was thoughtless, and did not mind what he 
id. I remember one occasion since then having been in his father's house, 
when his father was ordering him out of the house, for something he had done. 
I left along with him. Two days afterwards, when I was passing, his father 
and mother asked me if I had seen or heard an3rthing of him, as thev had no 
intelligence of him since he left. I said I had not seen him. We then 
searched the straw and hay in the stable, and after turning it over for some 
time we found the prisoner lying under it, nearlv exhausted. When lifted up 
be said he was only taking a rest to himself. At his side a knife was picked 
up. On being asked by a man named Clark what he was going to do with the 
knife, he said he was going to cut his throat with it. He then got some food, 
was taken into the house, and put to bed. Very frequently he wandered away 
from home for days. On these occasions his father and mother came and 
asked me about him. He was absent once about nine days. I once saw him 
walking to and fro in Norton Wood, when I asked him what he was doing 
there. He said he was " taking a walk to himself." I asked him to go home 
to his father's with me, which he did. He looked worn-out and fatigued, but 
was sober. I never saw him much the worse of drink. In driving his horse 
and cart alons the road, if anybody spoke to him he would allow them to go 
away along the road by themselves. I have on several occasions heard him 
speaking to himself, but I never could make out distinctly what he said. 
When ordered by either his father or roe to do anything, he would do it at 
once. When stationed at Portobello, in 1861, I met Bryce. Before that, I 
received a letter from his father, stating that he had been absent, and asking 
me, if I saw him, to send him home. I also got a message from his father, 
through the drayman, with a similar request. 1 met Bryce after that, on the 
street in Portobello. He came from the direction of Musselburgh, and seemed 
fatigued with travelling. I asked him where he had been, and he replied he 
had been taking a walk. I took him to my house, and save him dinner, which 
he ate ravenously. I afterwards took him to Edinburgh, and saw him off with 
the Ratho coach. On that occasion he never referred to his absence from 
home. I have heard the boys in Ratho say of him, " Here comes daft Geordie 
Bryce." When asked by the voung lads of the village to "stand* treat," he 
would take them into a public-house, and spend all his money with them. 

On crois-examinathnf the witness admitted that he had left the Edinburgh 
Police to avoid being dismissed ; tliat, having afterwards got into the Police 
force at Leith, he had been dismissed for giving prisoners drink on their way 
to gaol ; that, when stationed at Ratho, he frequently dropped into the prisoner s 
father's house, in passine, which was a public-house ; and that when the prisoner 
had left their house, and he went to look for him, at the mother's request, it 
was usually in a public-house that he found him. 

Jamea MeikU, station-master, Gogar. — ^I have known the prisoner for eight 
years. He often came about the station, on business for his father. I had 



1864.] TRIAL OF QEOBGE BRTCE FOR MURDER. 83 

occasion frequently to converse with him. He appeared to have an impedi- 
ment in his speech. He did not enter mach into conversation. I have seen 
him come into the station, look about him, and leave without speaking. On 
other occasions I have seen him come into the station in a fighting attitude — 
squaring with his fists. I have seen him come forward, ana pull me by the 
whiskers, and say, " Gome along with me ; yon are my prisoner ; what^s this 
youVe been about, sir ? " and so on. At times I humoured him ; at other 
times I could not afford to be bothered with him ; and sometimes I had to 
push him away. On these occasions he went away laughing, and looked half- 
witted. He often saluted me in military style, and asked me, " How are 
you to-day, Ck>lonel Meikle ? " He generally addressed me as *' Colonel '* or 
'* SeiKOftnt." He often asked for my wife, although he knew perfectly well 
that I was not married. He often looked unable to find words to express his 
thoughts. I would have trusted him with nothing about the railway or the 
station. I would not have trusted him with the management of the points. I 
gave an express order that he should not be allowed to meddle with them. I 
would far sooner have trusted a child of ten vears of age. I always considered 
the prisoner " half daft.*' In going about the streets, his mouth was usually 
open. I have seen him on the road, about a hundred yards behind his cart, 
with his arms crossed, gazing into the air ; and I have come up to within a foot 
of him before he observed me. I always found his memory very defective. I 
always found that he neglected to execute the orders I gave him for coals. 
He was a man of good temper, civil, and obliging. I never saw him under the 
influence of drink. There is a weighine-box at tne station, and when I wanted 
the prisoner I had only to go there, and I was sure to find him stretched upon 
a form — even when there were men about the station with whom he could con- 
verse. CroBS-excunined. — ^I do not think that silliness was shown only by him 
calline me colonel or sergeant. I thought he made himself too familiar with 
me, when, knowing that I was unmarried, he asked kindly for my wife, and 
pulled my whiskers. There were other features in his behaviour that con- 
vinced me he was not altogether sane — such as sending his horse and cart 
round the road by the passenser station — a distance of §00 or 900 yards (the 
only way by which they could leave the station) — while he himself went along 
the railway line, for a near cut. 

John Bryce, father of the prisoner. — The prisoner is one of a family of four- 
teen. From his youngest time he was always different from the others. He 
made very little progress at school, and I took him away from it. His 
peculiarity increased as time went on, but more so within the past few years. 
1 noticed a change for the worse upon him about ten years ago, when he joined 
the militia. He was enlisted for five years ; and was absent from home at first 
for about a year and a-half, and then occasionally for a few weeks at a time. 
I set him to drive my carts. He was sometimes at the farm, but very seldom. 
1 never tried him at anything else. He was very easily affected by drink ; two 
glasses of whisky would have put him mad. When he got the length of three 
or four glasses, he generally fell asleep. After this change for the worse came 
over him, he continued as before to wander away from home. He was away 
often for a week or a fortnight at a time. Sometimes I knew he had no money. 
He never told me where he had been ; but I often heard from people who had 
seen him wandering about. On these occasions, when he returned he looked 
as if he had had nuiny a hungry belly. On Sundays the family took their 
meals together in the parlour, but the prisoner preferred to eat by himself in 
a comer of the kitchen. About three years ago he appeared to be more 
peculiar. He became very restless, both night and day. At that time he 
began to drink a good deal ; but a change came over him about a twelvemonth 
ago. Since then I think he has been dnnking less, and he has fallen off in his 
body. I have often heard him muttering to himself. In October last he had 
a fit of drinking, and became very outrageous. I required to get him hand- 
cuffed. I asked the policeman to take nim to the station-house, for tofety. 
When his hands were shackled, he went to the room, and lifted a razor. It 
was taken from him. I went for Dr Craig, and asked him to go and see the 



84 MEDICAL NEWS. [JULT 

prisoner, because I thought there was something wrong with his mind. I have 
Known him leave his horse and cart standing at Ratho Station, and go away, 
without returning, for several days. The horse and cart were taken to the 
Quarry. I remember of his putting on his black clothes on a Sunday. About 
tnree years ago I went with my son-in-law to the stable. My daughter, Mrs 
Wilson, told me that Georee had told her he was to do something to himself; 
that in ten minutes he would be in eternity. The stable-door was locked. I 
assisted Wilson in by the hay-lofl, and he opened the door to me. I saw a 
rope in Wilson's hand. We brought away the prisoner, took him home, but 
he would not rest, and we tied him to his bed. On one occasion he wished to 
ffet into a room for his clothes, to go to Edinburgh, but his mother prevented 
him getting them, by lockine the door. He attempted to jump out by the 
window, but I seized him and pulled him back. For the past twelve months 
his brother William has slept with the prisoner. He was very unwilling to do 
so. On the Wednesday night before Jeanie Seaton was killed, the prisoner 
did not sleep in my house. On the Thursday morning I found him lying 
among some straw in the byre. He did not sleep in my house on the 
Thursday night ; but came out of the b^e on the Friday morning. He went 
to his work between six and seven on Friday morning. 1 had been from home 
on the Friday, but came home between six and seven, and found the prisoner 
sitting in the front room. I could not say whether he was sober. He went to 
bed l^tween seven and eight o'clock. I rose at two o'clock, and went into his 
bedroom. He was lyine with his head towards the foot of the bed. I rose 
again at five o'clock, and he was then lying properly. His brother, William, 
got up at five, and the prisoner about six o'clock. I saw the prisoner after he 
rose, out he said nothing. I did not see him leave the house. Afterwards a 
girl, named Isabella Brown, came for me to the house. My wife's maiden 
name is Agnes Fraser ; her mother's name was Catherine Nimmo. She had a 
brother named John Nimmo, whom I knew. He was not right in his mind. 
This John Nimmo's mother's brother's son was a minister, and went to America. 
John Nimmo's mother had another brother, who was not right in his mind. 

Mt% Bryee^ the mother of the prisoner, deponed to much the same effect. 

Mrs WiUcnj examined by Mr Fraeer^ deponed — ^I am a sister of the prisoner. 
I remember about three years ago of the prisoner coming into my nouse in 
Ratho on Saturday evening. He sat for about half an hour, and when he rose 
np to go away, he said that in less than half an hour he would be in eternity. 
He then went away, and I went and told my father and mother what he had 
said. I told my husband before going to my father, and he went away to my 
Other's after I came back. 

WUUam WiUon, porter, Ratho Station, deponed — I remember on a Saturday 
nighty about three years ago, my wife told me her brother had been at my 
house, and said that she was to look for his corpse in half an hour after that. 
I went down to the stable below my house. I found the door locked, and I 
went in through a hole above the door. I found George Bryce with a rope 
round his neck. It was tied to a beam. I took the rope off his neck, and 
went for his father, and we took him out by the hole by which I had entered. 
We could not get the key. He was in the loft above the stable, and the rope 
was tied to the beam ana round his neck. It was just above the hatch-hole. 
The rope had a runninc noose upon it. I recollect, about two years i^o, of his 
lying two days among hay in the stable-loft. I went to him several times, and 
asked him to come into the house. He returned me no answer. He got no 
food that I knew of during these two days. Crose-examined by the StwcUor^ 
General, — I went to the stable because I heard him lock the door. Did it not 
sound strange to you that he should tell you to come and look for his body in 
half an hour? Yes. It did not look much like an intention to take away his 
life? I don't know. You never heard of a suicide giving people notice 
to come and look for his body in lialf an hour? No. When you went 
to seek him you found him on his legs ? Yes. He was the worse of drink, 
but not much. I don't think he had become much addicted to drink by that 
time. He got worse afterwards. He was very violent when he got drink. 



1864.] TRIAL OF QEOROE BRTCE FOR MURDER. 85 

I always noticed him weak in the mind a little. If 70a pat a question to him, 
yott never got a right answer from him. 

JamiM Dick9on, pointsman, Ratho Station, deponed — I know the prisoner. I 
was at school with him, and have known him all his life. I thought he was 
deficient in mind. I remember on one occasion that he tamed his horse and 
cart right round in the way, when an engine was shunting tracks. He was 
deficient in memoiy. His mind appeared to wander. That condition of mind 
has grown worse since June 1863. He did not seem to be so tidy about him- 
self. He seemed to become more silent. Before that we often walked 
together, bat since that rather seldom. He rather shunned my company since 
that. Cro89-examined by the SolicUor- General, — I have seen hmi send his horse 
away from the station, and did not follow it himself. This was about the 
'^daftest** like thing I ever knew him do. He made very many mistakes. 
Interrogated, Will you tell us one ? I gave orders to send my trnnk to the 
station, and it never came. Who did you tell ? Somebody connected with 
the house. Did you speak to the prisoner about it ? Yes, afterwards. Let 
us know the biggest mistakes he ever made ? He quarrelled with his father 
about putting ^e horse*s bit in its mouth, and although he was wrong he 
would not admit it. Will you give us an iuMtance of how he answered one 
question by referring to another ? I cannot exactly do that. 
, Professor Layeoek, examined by Mr Fraeer, — I am Professor of the Practice 
of Medicine in the University of Edinburgh. I have examined the prisoner 
twice in prison — on Wednesaay last and ^resterday. I subjected him on both 
occasions to minute examinations on a variety of subjects, with a view to ascer- 
tain -his mental condition. He has a low type of physical organization. By 
the form of the head, the &ce, the jaws, and the mode of articulation, I am able 
to tell this. He has a small head, a receding forehead, and superciliary ridges. 
His articulation is thick and indistinct, which is often the case among persons 
of low organization. I have heard the evidence given to-day, ana I have 
examined him, and I do not consider him to be in his sound senses. I do not 
think that, on the morning of the murder, he was in his sound senses. [By die 
Court. — Does that depend on whether he committed the deed or not ? No.] 
I think at the time he was suffering from maniacal excitement. That tit might 
come on suddenly and go off suddenly. This is not uncommon in homicidal 
mania. It is one of the characteristics of the fit that, after a person comes 
out of it, he does not remember what he has done. The prisoner might, at a 
subsequent period of the same daj on which he committed the deed, appear 
to ordmary observers as quite rational. My conclusion is adduced from the 
fiict brought before the Court, that for some years back he has been in a morbid 
state, and I conclude that about twelve months ago he began to suffer a further 
change of a morbid kind, which we term chronic dementia, and which in similar 
cases has been observed to pass into complete dementia. The suddenness of 
the attack without any apparent immediate exciting cause also led me to the 
conclusion to which I have come. The fact that the symptoms detailed by 
the different witnesses indicated that he is of a class to suffer that kind of 
madness. The conduct of the man during and after also led me to the same 
conclusion, as these cases of homicidal excitement are characterized by the 
reckless fury which I found exhibited here. After the deed is done, the 
patient has no recollection of it. I think any person in that morbid condition 
would be more excited after he had received tne blows on the head from the 
umbrella. Homicidal and suicidal mania are very often combined in the same 
person. When I saw the prisoner yesterday, he aid not remember that he had 
seen me on Wednesday. He did not, I think, pretend he was insane in prison. 
I believe he was suffering yesterday from disease of the brain, which impaired 
his memory ; and I was quite sure he was not feigning. It is usually held 
that a person in whose relations insanity has appeared, is more prone to the 
disease than one among whose relations it has not appeared. A very eminent 
authority on the subject of insanity says that it is more readily transmitted by 
a female than a male relation ; but I will not give an opinion on such a difficult 
subject. Oroee'eoKunitted by the SoUdior- General, — ^I assume the fit came upon 



86 MEDICAL NEWS. [jULY 

the prisoner after he had left his father's house that morning. I assume that 
he jumped over the wall and attacked Jeanie. I assume the fit must have 
passed off some time between the commission of the deed and when he first 
saw Richardson. Assuming that he was running for an hour and a-half, was 
the fit on him then ? I am unable to give an opinion. What is the cause of 
your inability to give it ? I know of no case similar. Although he had run 
for an hour and a- half, I would still think that the fit had gone off about the time 
Davidson first saw him. My opinion is, that after he was informed that he had 
killed Jeanie, he ran away. I account for his running away through fear, appre- 
hension, delusion. I assume there was a delusion on his mind, and that he was, 
when the deed was committed, ignorant of having done it. I think the attack 
on the girl had to do with his previous enmity, but I do not think the attack 
was to gratify the enmity he had against her. He did not know what he was 
doing. Is it your opinion that he knew who she was when he was attacking her ? 
I have no opinion on that subject. I have no medical opinion to the effect that 
he did not know what he was doing. I do not assume that he knew whether 
what he was doing was right or wrong. I think he did not know what he was 
doing. On previous occasions, when excited, he said he did not know what he 
had done, in the whole history of the case, so far as I have heard it, I think 
his delusion was that he thought Jeanie called him a drunken fellow. I have 
heard of such delusions. I have frequently known cases of insanity with no 
jpreater delusion than this. If that was no aelusion, then there was no delusion 
in the case at all. He had a delusion, for instance, that his father's horses 
were his own. I think he showed that he was an imbecile in memory and 
in judgment. He had in some cases no memory at all. What do you mean ? 
Can you give us an instance ? I must appeal to the Court. I have been here 
since ten o'clock this morning, and I must say that I am perfectly exhausted. 
Without referring to the notes which are in the hands of the advocates, it is 
impossible for me to give the instances desired, for I took no notes. From the 
opmion I have formea of him he was a man liable to brood over a real or sup- 
posed wrong. That brooding, and the enmity it would excite, might induce a 
fit of maniacal excitement, and a desire to cut his enemy's throat. Ee-exam' 
ined by Mr J^Voaer.— The prisoner had a tendency to this fit of maniacal 
excitement before he went to Mr Tod's villa on the Saturday morning. His 
sleeping in the byre on Thursday evening indicates, I think, a morbid condi- 
tion, in forming my opinion to that effect, I have taken into account all the 
facts that I have heard proved. It not unfrequently happens that people in 
that condition run away and hide themselves. A man may be a lunatic while 
ordinary observers think him sane enough — that is very common. It is often 
very difficult for experienced men to discover that a man is a lunatic. 220- 
craas-examined by this SolicUor- General, — If a lunatic is unconscious of what he 
has done, even although that should be wrong, will he attempt to escape ? 
No ; he has no reason to escape in that case. And if a lunatic does what he 
thinks is quite right, will he still try to make his escape? Did you ever 
know of such a case ? I cannot tax my memory at the present moment. You 
must remember I have been here for fifteen hours. By the Court.— Ib it a 
common thing for a person with suicidal mania to announce beforehand his 
intention to kill himself? That is very often the case. There are certain 
persons who commit suicide to punish those that offend them ; and where the 
affections are wounded that has very often been the case. Do you think that 
in the case before us there is anything of that kind? I think so. The 
announcing of his intention was an indication of a weak mind. Do you con- 
sider that the prisoner is insane now? I think so. He is labouring under 
insanity — a form of chronic dementia which will go on increasing ; and I con- 
sider the disease incurable. 

Dr Robert Ritchie, who, being examined by Mr Eraser, deponed, — I was 
formerly resident medical officer at Bethnal House Medical Asylum at London. 
I was tnere for three years and seven months. I had on an average about 300 
TOtients in that institution. I left it in March 1861, to commence practising in 
Edinburgh. I am now physician to the Royal Dispensary, and extra-physician 



1864.] TRIAL OF GEORGE BETCE FOR MURDER. 87 

to the Sick Chfldren*8 Hospital at Edinburgh. I have examined the prisoner 
with the view of examining his state of mind. I saw him three times in jail. 
I saw him first on the 18th Ma^, then on 23d May, and then on 25th May. I 
have also seen him this mommg. I have also heard the evidence that was 
adduced yesterday. I would caU the prisoner a man of low mental organiza- 
tion. In my interviews with the prisoner I subjected him to a long examina- 
tion. I took him over his whole life so far as I could ascertain from his 
description of it. I commenced at his early days, and tried to trace what facts 
in his life had made the chief impression on his mind. He gave me to under- 
stand that it was his belief that he was sane. [By the Court. — ^I put the ques- 
tion. But when I asked whether, when he threatened to commit suicide, he 
considered he was sane, he replied that he did not know whether he was then 
sane or not.l I could not have come to the conclusion that he was decidedly 
insane merely from examining himself with reference to the evidence. I was 
particularly struck in the evidence yesterday by the fact that he aopeared to 
nave become decidedly worse about three years ago ; and that a further change 
had occurred about one year ago. The change that occurred one year ago 
was an evidence to my mmd of delusion. His bodily health apparently became 
worse about a vear ago, from the evidence yesterday. One great evidence of 
that was his sleeplessness ; and I think also his mother stated that he had 
evidently become feebler, and there was also an increased restlessness. There 
seemed to be a change to the worse. As far as the cerebral state seemed to 
be indicated, there seemed to be a change to a melancholy condition, with a 
tendency to commit suicide. These symptoms, occurring in the order they 
did in this case, I regard as indicative of cerebral disease. I have had occa- 
sion to notice this frequently in the patients under my own charee. I would 
regard the sleeplessness as an incipient stage of insanity, though it does occur 
in all stages. Suicidal mania and homicidal mania are very frequently com- 
bined. I would expect the man having a tendency to commit suicide as likely 
to have a tendency to commit homicide in many cases, but I would not say 
that it is so in every case. Do the insane who are under homicidal mania 
frequently show great skill and cunning wherewith to effect the death of some 
person they hate, aud patiently wait for an opportunity of effecting their pur- 
pose ? They do. Is it also common, after an insane person has committed 
nomicide, to make an attempt to escape from punishment ? I cannot answer 
that from my own experience ; but it is not uncommon for a lunatic who has 
done an act to tr^ to escape punishment for that act. I cannot recall an 
instance of a lunatic who has done an act, or who has been told he has done it, 
attempting to escape from punishment. It is very common for lunatics to 
suppose that they have been slandered by people. It is a fact that medical 
men often cannot discover insanity by an examination of a man himself without 
reference to his past life. Assumme that the prisoner committed the act with 
which he is charged, I do not consider that he was of sound mind when he did 
so. In my opinion, he was in a state of maniacal paroxysm when he committed 
that deed. He had a tendency to that, I think, before he left his father's 
house. I think that when he passed the gate the sight of the place probably 
brought the girl to his remembrance, and that brought on the paroxysm. 
After such maniacal paroxysms are over, it is common for the person who has 
been under them to have no recollection of what he did when under them. 
From the evidence given by his mother as to his state in October 1863, when 
he was strapped down, I have no doubt that he was then under a paroxysm. 
I would have recommended then, had I been called in, that he should be sub- 
jected to restraint. I think his pulling out the knife to Ijord Morton^s men is 
only one of the many instances I heard in the evidence which indicated his being 
of an impulsive tendency. As to the evidence as to absence of mind, abstraction, 
gazing at' the stars, and such like indications, I would not infer from any 
one of these that he was insane ; but in this case, with the distinct progression 
of these indications, I would infer that they indicated that the man was gradu- 
ally becoming insane. The disease gradually progressed. There was a change 
in June, then there was a paroxysm in October ; and from the evidence and 



88 MEDICAL NEWS. [jULY 

my own inspection of the man, I would infer that the case would gradually 
progress towards dementia. I mean by that that it would end in total loss 
of intellect. I think he is now in a quiet state, but that the delusion under 
which I consider him to labour stiU exists. I still consider him insane. 
Croaa-examined bjf the Solicitor- General. — Do you use the term dementia as 
something different from insanity ? I mean to say that dementia is one of 
three divisions of insanity — ^mania, monomania, and dementia. Do you consider 
the prisoner to have dementia ? No, I consider him to be just now a mono- 
maniac? According to the assumption you make of the fact, you were of 
opinion that he was a monomaniac on the 16th of April last ? Yes. When 
did he become a monomaniac ? About a year ago. So far as I know, the 
subject of that monomania has been the same. What is the subject of that 
delusion ? A delusion regarding certain statements alleged to have been made 
by Jane Seaton — statements which she never had made. That is the only 
delusion you have any notion he is labouring under? Yes ; but I have reason 
to suspect otherwise, although I could not say positively. Then, if that was 
no delusion, which yon mentioned as the only delusion, tnere is no delusion at 
all, and he never was a monomaniac ? There is other evidence of progressive 
changes in his mind. There was one reason, namely, that of wishing to dine alone 
on Sundays, which I think was not sufficiently brought out. Why, because he 
had suspicion of his family. Suspicion of what ? I cannot say in what respect, 
but to my mind it appears tluit he suspected that they would do something to 
him — ^at least that may have been the case. I am merely offering that as my 
opinion. As a guess? No; as my opinion founded on other cases. You 
think his family had offended him, and he had a dislike to them ? Not exactly 
that. SoL' Gen. — It appears to me very much like what I have observed in other 
cases of a person havingHeparated himself from his family, in the belief that they 
had offended him. Drii, — Another reason I have for considering he had a delu- 
sion was that he muttered to himself, and I think he then considered somebody 
was speaking to him. The only delusion which influenced you was that which 
he had in connexion with Jane Seaton ? Yes. Have you K>rmed your opinion 
entirely from what has come out in the proof? I have. If that was no 
delusion, was there an^ delusion for your opinion to rest upon ? No. Do 
you think that his mind was capable of entertaining, for a Ions time, a 
feeling of enmity or ill-wiU against a particular person ? I think it was. 
Do you think his mind was capable of entertaining a strong desire to gri^tify 
that feeling of ill-will by doine an injury to the person ? The fact of his hav- 
ing a delusion would not, I thmk, keep him from gratifying his feeling of ill- 
wSl. The delusion may have produced that feeling. Do you think his mind 
was competent to understand the full nature of the injury he inflicted on that 
eirl ? I cannot say for the time when he committed the act. I understand 
urom that that there is no fact in this case that can lead you, as a medical 
man, to come to the conclusion tliat he did not know what he was doing when 
he committed the deed ? (No answer.) Have you any reason to doubt that 
he knew the girl whom he attacked was the girl tnat injured him ? No. Have 
you any reason to doubt that he attacked her in consequence of that feeling of 
enmity towards her ? I believe he did attack her in consequence of that feel- 
ing while labouring under a delusion. You think that the feeling of enmity 
proceeded from a aelusion, but that it was the feeling of enmity wnich caused 
the attack? That would be somewhat different from what I already said. 
Very likely. Have you any reason to doubt that, when he drew the razor 
across the girl's throat, his desire was to kill her ? I cannot say that it was 
his desire, but it was evidently his intention to kill her. Now, have you any 
reason to suppose that he thought it was right and i.ot wrong to kill her? I 
cannot say. Have you anything which enables you to form an opinion one 
way or other whether he thought it was right or wrong to kill the woman ? 
No. I cannot say whether he thought it was right or wrong, as I cannot 
entirely enter into his state of mind. Of course not ; you cannot entirely 
enter into the state of any man's mind. The Solicitor' General — It comes to this, 
then, I think. He knew the girl ; he had a feeling of enmity towards her, 



1864.] TRIAL OF QEOBOE BBTC8 FOR MURDER. 89 

arising from a ddaBion, fiuic3riiig that she had injured him when she had not. 
He hiui a deeire to gratify that f(Mling of enmity, and he kQled the girl. Have 
yon any reason to suppose that by so doing he imagined he was doing right ? 
2>r JUichi&^lly opinion of the matter is that he was acting under a delusion, 
and while under that delusion he had a sudden monomaniacal paroxysm, and 
in that paroxysm he committed the murder. Be-txamin&d by Mr Fnuet — ^Is it 
common in lunatics to entertain a feeling of enmity and ill-will ? Yes. Is it 
not a very prominent characterbtic in cases of aelusion ? It is. Knowing 
the person quite well against whom they entertain the ill-will? Homicidal 
attacks are caused very often by delusion. I haye had a case of the kind 
nsyself, where a patient thought I was writing things against him, and when he 
brought large stones into tiie institution with the intention, I have no doubt, of 
killing me. This is a danger which the physicians in such establishments run. 
If Br^oe committed tho deed under the delusion that he was slandered, was 
his mmd capable of understanding the case ? I take this case to be like my 
own, where ne was acting under a delusion. [The Lord Pretidmt — But the 
question is, Was he capsBle of understanding that he was acting under a delu- 
sion ? I do not think he knew he was acting under a delusion.] Mr ProMtr 
— ^Before the paroxisms in October and April, were there all the symptoms of 
incipient monomania ? There were symptoms a year before. He entertained, 
when I spoke to him this morning, the same delusion in regard to the girl 
Seaton. 

This concluded the case for the prisoner. 

The SoUcUor-Qmetal for the Crown, and Mr Fraeer iot the prisoner, 
addressed the jurjr. 

The Lord jugiic&'Gkneral proceeded to charge the jury. In the course 
of his charge, his lordship laid down the law as to insanity in the following 
terms : — Insanity, in a general sense, may be of various kinds. It may be 
imbecility or fatuity. That is not the case before yon. Or it may be yiolence 
— a mama leading to yiolence, which is said to be the case before you. That 
may be of various kinds, but what we haye to deal with here is said to be 
monomania. It is said that in a paroxysm of that disease the prisoner com- 
mitted the offence. The disease is what constitutes the unsounoness, and the 
paroxysm Lb only an event in course of the disease. Now, the opinion expressed 
in substance by both the medical sentlemen is that he was at the time under an 
insane delusion — a delusion which shows that he was insane — ^and that it waa 
acting under that delusion that led to the perpetration of the act, and that in 
eonse^uence he is to be reabrded as a person not responsible for it. I think it 
was said, especially by Br Ritchie, in the concluding part of his evidence, that 
the only delusion proved was the delusion he was labouring under in believing 
that a man of the name of Peat had told him that Jeanie Seaton had said he 
was a drunken blad^nard. I need not tell you it is not every eccentricity 
that is a defence against the perpetration of a crime. It is not the mere cir- 
cumstances of od£ty that will be a defence against a criminal charge. It is 
not that the intellect is more or less weak that can constitute such a defence. 
The defence in the present case is that he exhibited an insane delusion, which 
insane delusion being acted upon, led him to the perpetration of the offence, 
and that therefore he is not responsible. Delusions may be of various kinds. 
There are delusions which are dearly indicative of insanity. There are cases 
of men and women who have believed themsdves to be some great persons of 
antiquity, of men who believed themselves to be constituted of particular 
materials, of men who believed themselves to have existed before the flood ; 
and there is also the case of a man who believed himself to be the Deity. All 
these strange, supernatural ideas, if they are really entertained, are conclusive 
evidence of insamty. There is no doubt of that. But there are other kinds 
of delusions which are not evidence of insanity. A man labouring under a 
mistaken belief respecting himself is not necessarily insane. A man believing 
that another has an iU-wul towards him is not therefore insane, however ill- 
founded the notion may be. There are various errors of judgment, leading to 

VOL. X.— NO. I. M 



90 MEDICAL NEWS. [jULY 

wrong inferences, deduced from facts observed — strong opinions entertained on 
insufficient grounds, leading to erroneous conclusions. These may be called, 
more or less, delusions, because there is no good foundation for the opinions 
that are entertained. But delusions of that kind are not such as will screen a 
person who, on acting upon them, has perpetrated a crime. If you choose to 
call that insanity, still it won't do. It is not an insanity of the kind that will 
be a defence against the consequences of such an act as this. Now, what is 
the nature of the case ? The nature of the case here is this, that this man 
believed that Jeanie Seaton had said to Margaret Gibson, who had repeated it 
to Peat, that he was a drunken blackguard. Now, Peat says he never told 
that to the prisoner, and Margaret Gibson says she never told that to Peat, 
and that Jeanie Seaton never told that to her ; so that the chain of communi- 
cation, so far as the witnesses go, is broken. But supposing that he is under 
the impression that he had heard it from that source, and supposing it was not 
true, it does not necessarily follow that he is insane, so as to be irresponsible. 
It appears that the opinion was entertained at Mr Tod's villa by some of the 
people there, that the prisoner was a person addicted to drinking ; and it does 
appear that Mrs Tod had told Jeanie Seaton — had told the servants, all of them 
— that if he was a person of that kind, his visits ought to be discouraged. It 
does appear — as probably you will be satisfied — that Jeanie Seaton had enter- 
tained the opinion that he was a worthless, drunken fellow ; and it is very 
likely that she may have said so. It would appear from the evidence that she 
had said that to her mother and to her father-m-law ; and it is very probable 
that such was her opinion. It may have been true that she influenced the 
opinion of Lizzie Brown, to whom he was paying his attentions. That story 
may or may not have got circulation so as to come to his ears. He may have 
drawn conclusions that this was her view, and that she had been stating it. 
He may have been, in believing the delusions, labouring under mistake as to 
Peat being the person who told him ; it may have been somebody else that 
told him. But is that to make him irresponsible for the act of murdering Jane 
Seaton ? If a man has a delusion on any matter, however slight or frivolous, is 
that a reason for absolving him from the penalties of the law when he has 
incurred them ? We must consider the consequence of absolving persons that 
are without restraint, of absolving them from the effects of the law when they 
commit acts of violence ; and it is for persons so pleading insanity, to make 
out something that is a good answer to the charge. Is it a ^ood answer to say 
— << I was under the delusion that Jeanie Seaton had entertamed the opinion of 
me that I was a drunken blackguard, and had expressed it to others ; that I 
was under the delusion that I heard it from Peat, who got it from Gibson ? " 
I am of opinion that that will not do. llie delusion must have reference to 
something far more serious and far more warranting and proroptins to the act. 
If a man is under the delusion that another is assailing him to take away his 
life, then he may be justified in retaliating by taking away the life of the per- 
son who he believes is attacking or plotting against his life. But that a person 
has merely the idea that some one has said something of him, which he himself 
probably is conscious is not unfounded— to hold that as an excuse for taking 
away the life of that person is quite out of the question. It nmy be an indica- 
tion of insanity taken with other matters, but it is not so standing by itself. 
But would you require to have it established beyond all doubt that the delusion, 
whatever it was, or the belief, was wholly groundless ? Would you require to 
have it established that nothing of the kind took place ? You are asked here 
to go into that inquiry, and on doubtful evidence to decide whether she ever 
made that statement in regard to him ; and then, on the result of that inquiry, 
you are to build this theory of insanity, and on this theory of insanity, in reference 
to a matter so trifling, the man is to get impunity who commits murder. Gentle- 
men, the question of insanity — of insanity to the effect of relieving a part^ from 
responsibility — the question of whether a man is insane or not, is a question for 
you to decide. It is a question on the whole facts of the case ; it is not a medical 
question. The medical gentlemen have opportunities of observation which make 



1864.] TRIAL OF QEOROE BRTCB FOR MURDER. 91 

their testimony firequently very important in reference to such matters ; bat the 
qaestion is not a medical question ; it is a question of fact whether the insanity 
amounted to this, that he was doing a thing which he himself considered, and 
had grounds to believe, and respectmg which his beKef was a sincere one, that he 
was warranted in doing — whether he really believed that something had occurred 
which would be a ground for taking away the life of this unfortunate girl. It 
is a question for you whether his state of mind was such as to warrant you in 
sustaming this defence. It is no doubt true that, if the result of your inquiry 
should be that the prisoner committed this act in a state of insanity, he would 
not be let loose on society. The public must be protected against persons who 
have uncontrollable passions, but I can by no means endorse the doctrine that 
seems to be held, that when a man cannot control his disposition to do an act 
he is not responsible for it. Nothing is more common than a person being 
unable to control his passions. His passion gets the better of him, and he 
becomes for the moment beyond control. But merely because vou call it a 
paroxysm of monomania, that is not a reason for holding that such persons are 
to be held as out of the pale of the law in regard to answering for the conse- 
quences of the crime they commit. But the result would be--if you are of 
opinion that he is insane — immediate restraint, and, as Mr Fraser said, possibly 
subsequent restoration to society. But no matter for that ; the qaestion you have 
to decide is, has it been establbhed or has it not, that this act was perpetrated 
through insanity ) — insanity in this sense, that the party was bereft of mind, 
that he believed, from grounds that acted upon his imagination, that facts had 
occurred which warranted him in committing violence ajsatnst this individual. 
The prisoner is said to have no recollection whatever of what happened, and 
that want of recollection is said to be a very common sequel to a paroxysm of 
mania. It appears that when he left his father^s house he had taken with him 
a razor. It appears that he met some people on the road, that he met a baker^s 
boy not &r from Mr Tod*s villa, and that when he met him he passed on 
beyond the house, and entered the grounds, it is supposed, further up by climb- 
ing the wall. Now, it is remarkable that, while he states that he aoes not 
recollect what he did to this woman on that morning, he did recollect that he 
had gone to Mr Tod^s house. He did recollect that he had seen the cook in 
the premises, and that he did recollect he had been in the kitcheu. He knew 
that the razor which was exhibited to him was his, and he says he does not 
know how he came by it. In short, he pleads want of recollection of the par- 
ticular act that he dia in committing the murder, or of the possession of the 
particular weapon, but he remembers all the other circumstances of the case. 
If he was not m this state of mental aberration when he left his father^s house, 
or until he got to the house of Mr Tod, it is strange he should not recollect 
how he got the razor. He recollects perfectly well having seen Hunter, and 
having been in the kitchen ; and when he had committed the last assault on the 
deceased, and cut her throat, he immediately fled. He was pursued, but was 
apprehended and taken back ; and when spoken to bv the constable, he remarked 
that she was cheap of what she had got, and asked if she was dead. This is 
not like evidence of a total want of recollection. The allegation of want of 
recollection is one thing, the proof of want of recollection is another. It is 
not proof that a man does not remember that he says he does not remember; 
and if he remembers things occurring about the time, but abstains from giving 
any information as to the particular thing he is charged with, you will judge 
how far you are to take that as a total want of recollection on his part. But 
this want of recollection is not a very unfrequent thing on the part of persons 
accused of crime. I have said that he carried on his ordinary vocation as a 
carter, and I think it is also in evidence that he was in the miUtia, and that he 
was out on duty for weeks at a time ; and we have no evidence that he was 
incapable of performing his duties there — nothing of that kind. There is no 

Eroof that he was an imbecile, or that he was not trusted in the work which 
e did perform. Sometimes, it is said, he left his cart in jeopardy ; sometimes 
he leftnis horse and cart altogether, and did not appear for days. He is a 



92 MEDICAL NEWS. [JULT 

person, it appears, of erratic dispositioii — and this tendency may account for 
all that — ^bat that he did carry on his occupation, and that he was regarded by 
those persons who came in contact with him as perfectly competent to do these 
things, and not as a man who was exempt from responsibility for the conse- 
aaences of his acts. Is it, then, the case that he suddenly becomes insane, 
tnat he could no longer be held responsible for his acts ? — ^that is a question 
for you to consider. It is not enough that the eyillence shows him to be a man 
of unsettled disposition ; that will not exempt htm from being responsible. He 
is guilty, unless you hold him to be insane. If you are of opinion that he is 
insane now, it is ^rour duty so to find ; it is your duty to say so separately, and 
without pronouncing any opinion on the question of guilty or not guilty- If 
' [; he IS sane now, but that he was insane on the loth of 



you are of opinion that 1 

April last — ^insane in the sense of not being responsible — ^you will find that he 
is not guilty by reason of the insanity which was on him at the time. If yon 
are of opinion that he was not insane at the time, and not insane now, your 
verdict in that case will simply be a verdict of guilty. 

The jury having retired, returned a verdict of guilty, with a recommendation 
to mercy on account of the low mental organization of the prisoner ; in respect 
of which verdict the prisoner was sentenced to death. 



OBITUART. 



THE LATE PROFESSOR MILLER. 

The unexpected and premature death of Professor Miller, which took place on 
the morning of the 17th June, will be sad news to many an old friend, to many 
confiding patients, and to a whole generation of pupQs in every quarter of the 
globe. For several years past, Mr Miller's friends have observed with distress 
that his fine &ce and manly figure were not as once they were and should 
still have been; that his expression was often haggard and exhausted; and 
that he was yielding gradually to the continued strain of overwork. Of this 
he himself frequently admitted the truth, and he wisely allowed himself longer 
periods of summer holiday than had been his wont. During these holidays 
he paid repeated visits to Homburg and Schwalbach, and evidently derived 
much benefit from the use of the chalybeate. But although he thus far took 
proper care of his health, he continued to abnegate the use of stimulants to a 
degtw which many of his friends thought prejudicial to him ; he was not an 
inflexible teetotaller whom no advice could convert even to the temporary 
use of wine for his body's sake ; but he was at the same rime so zealous and 
scrupulously honest a nephalist, as he called himself, that he immediately 
gave up the use of wine when the distmctness of the need for it became 
obscured. He would not consent to become a habitual drinker of wme on any 
terms. Whether this was a just decision in the case of a man who had for 
the greater part of his life used stimuUnts moderately, and who had far too 
much and too anxious occupation of body and mind, we shall not here attempt 
to decide. So great also was his devotion to the advancement of religion and 
of social ameliorations, that he was undoubtedly, and often not in ignorance, 
led to add to his strictly medical engagements a very great amount of business 
and hard work, more than any ordinary man can continue to bear. And he 
was not a strong man ; he had been treated for pericarditis by Dr Abercrombie ; 
he had an almost constant but varying dyspepsia; he had frequent slight 
attacks of gout, which he inherited from his father ; and he had some ten years 



ISM.] THE LATB PR0FE880B MILLER. 98 

before Us death eontracted, hj a prick of his bwtoary, an infoctieD whieh 
oould not but add materiidly to his other eonroee of weakness. Latterly, he 
became increasingly dyspeptic ; then he grew decidedly hypochondriacal ; from 
gay he became gloomy. This state of mind abont a fortnight before his death 
greatly deepened ; active disease of the brain showed itself passing on to a 
state of imperfect coma, in which he continnad till the last. Only in his last 
hours he was able, with a dear mind, to bid his £unily an affectionate adieu. 
He died at the age of fifty-two. 

Like many of his eminent Scottish compeers, Mr Miller was bom in a manse. 
His fiither was the minister of Eassie, in Forfarshire. Possessed of more thaa 
ordinary erudition, a man of great energy and of a fine presence, highly and 
widely esteemed, the Beyerend Mr Miller fonnd himself surrounded by a large 
liunily, in which the subject of our sketch held the place of third son. Jamea 
was bom on the 2d April 1812. His next elder brother is the weU-known 
Beverend Dr Samuel Miller of Free St Matthew^s, Glasgow, and his yooi^gest 
brother is now a surgeon in Her Majesty's Indian Army, The minister of 
Bassie brought up his boys under his own eye, and to a great extent under his 
own direct tuition. The manse was for a time indeed a small school, for, 
besides his own fiye boys, the minister was intrusted with the education of 
William and Lauderdale Mauk, sons of his patron Baron Panmure. From this 
grammar-school James Miller was sent to the University of St Andrews in 
October 1824, where his general education was carried on and completed in 
three winter sessions. He here came in contact with Dr Thomas Chalmers, 
who was one of his teachers ; and here he made the acquaintance of many who 
now lament his death, among whom we may name, Sheriff Jameson, Rev. Dr 
Robert Lee, Lord Jerriswoode, and ReT. Dr Lindsay Alexander. 

In the summer of 1827, he b^an to prepare for professional education, by 
being attached as a pupil to Dr Ramsay of Dundee. Bad health, however, soon 
broke up this connexion, and in the same year he went to Edinburgh, and 
began the regular career of a medicid student under Mr Mackenzie. In 1832, 
he received the license of the Royal Ck)Uege of Sui^eons. During his student 
life the chief teachers in the school were, Monro, Knox, Lisars, Christison, 
Syme, Graham, Duncan, Home, Hope, Alison, Mackintosh, John Thomson, 
Tumer, Russell, Ballingidl, Mackenzie, etc., and it is to them that he owes more 
or less directly his primary medical Instraction. 

Now a surgeon, he became attached to Listen, whose favourite pupil he had 
previously been. Of the nature of this connexion we can say little. Only 
Miller was Liston*s assistant ; he was also a devoted friend and admirer. And 
he not only did the ordinary duties of surgical lieutenant to Listen, but afforded 
him very great aid in the production of his well-known works on Surgery. 
Liston went to London in 1834, and wished to draw his young friend after him, 
but Miller preferred to cast his lot in the metropolis of his native country. 
At the great ovation to Liston, given him by his more distinguished Edinburgh 
friends, Mr Miller was, in some sort, named as his successor; and the fact is 
that he rapidly fulfilled the expectations formed of him, becoming at once a 
fully employed and popular practitioner. About the period of his commencing 
practice he was also dosely connected witli Professor Monro, for whom he 
executed much literary work in connexion with his book on the Gullet. 

On 11th July 1836, he espoused Penelope Garden Campbell Gordon, 
daughter of a military officer and of an old and well-known northern fiunily. Of 



94 MEDICAL NEWS. [JULT 

thifl marriage the issne is Beven children ; — James, now a sargeon in the East ; 
Elizabeth, now wife of Dr Patrick Heron Watson ; Alexander, now a medical 
student ; and four younger children. 

In 1842, the death of Sir Charles Bell produced a Tacancy in the chair of 
Surgery in the University. To this important office Mr Miller was appointed, 
after a severe struggle with Dr Argyll Robertson and Mr Lizars, his competitors. 

In recent times no Scotch medical man has enjoyed a wider reputation or 
secured a more lucrative practice. He recruited his patients not only from 
these isles, but also from various parts of the four continents. Whoever was 
his patient was also his friend, and continued his friend. Mr Miller*s practice 
was by no means confined to surgery. Besides his suigical practice, he had 
considerable eroplojrment as a general practitioner, and was much consulted 
as a physician both in his own house, and in every part of the country, as 
well as in England. 

Mr Miller was a bold and dexterous surgeon. We are not aware that he had 
any special hobby among operations, but he was reputed as specially skilful 
in dbeases of the rectum and bladder, in which his experience was very large. 
He was always averse to having recourse to the knife without an evident in- 
evitable necessity, and in many passages of arms has defended with his lance 
what he called conservative surgery against the more zealous men of the craft, 
whom he justly believed to be drawn by an inevitable prolixity into an excessive 
confidence in the knife. In illustration of this peculiarity, we may mention 
the great zeal with which he espoused the modem treatment of tubercular 
diseases by constitutional remedies, and the satisfaction he had in saving limbs 
for scrofulous patients, who would in his youth have been at once placed on 
the operating table as their only source of hope of cure. 

Mr Miller is well known to have been a successful teacher. He had always 
large and attentive audiences. In his course he used his " System** as a text- 
book, but did not adhere to it at all slavishly^ on the contrary, he regularly 
made fresh notes for the lecture of every day. His lectures were copiously 
illustrated by diagrams, firesh dissections, and preparations from his own and 
the other rich collections of the University. In speaking of his teaching, we 
cannot omit mention of his extraordinary fluency of English diction. This 
valuable talent was but of little service in his didactic occupations; but 
when he had occasion for it, and had had time for some preparation, he was 
equal to the great orators of the day ; the audience, whether sympathetic or 
not, was always delighted with his handsome form, his simple gestures, his 
fine voice, hb elegant diction, his abundant wit, his occasional humour. There 
can be no doubt that had he been fiivourably situated for the exhibition of his 
powers in this way, he might have reached the highest rank among public 
speakers. 

As we have no desire to encroach on the functions of the biographer, we 
shall not enter on the private life of the deceased. Without derogating in 
any degree from Mr Miller's high character as a public and a professional man, 
we are sure his personal friends wiU join us in asserting that it was in private 
life that Mr Miller's beautiful character shone to the greatest advantage. It 
was impossible to know him intimately without becoming increasingly fond of 
him. His powers as a good companion were unrivalled, and for a great part of 
his early life he was much in society, being everywhere courted for his genial 
wit and abundant humour, and for every good quality and talent of a host or 



1864.] THE LATE PB0FE880B MILLER. 96 

of a gneit. After the Dismption of the Church of Scotland he devoted so 
miich of his spare time to the interests of religion and of the Church, that he 
necessarily greatly contracted the circle of his friends in general society. Bat in 
the new sphere he acquired a host of new and zealoos friends and admirers, who 
looked ap to him no less as a man of ability and of power, than as one whose 
straggle to lead the life of a true Christian demanded their admiration and 
imitation. In his latter years he became more and more devout, and of him it 
may be truly said that he died in the glorious hope of a joyful resurrection. 

Mr Miller had been President of the Medico- Chirurgical and of the Harveian 
Societies ; and, at the time of his death, was a Fellow of the Royal Society 
ttjid of the Royal College of Surgeons ; Professor of Pictorial Anatomy to the 
Royal Academy ; Surgeon in Ordinary to the Queen for Scotland ; Consulting 
Sorgeon to the Royal Infirmary ; Surgeon to Chalmers' Hospital for the Sick 
and Hurt; Consulting Surgeon to the Royal Hospital for Sick Children. 
Besides, he held several honorary diplomas from Continental and American 
medical institutions. 

The following is a list of Mr Miller's principal published writings : — 

1. Probationary Essay on the Dressing of Wounds, as Simplified and Improved 

in Modern Surgery. Written when a can^date for admission to the 
Fellowship of the Koyal College of Surgeons. 1840. 

2. Chapter on the Restoration of Lost Parts. — Listen's Practical Surgery, 1837, 

1846. 

3. Principles and Practice of Surgery. Two volumes, duodecimo. Also 

three editions octavo of the same work. 

4. A System of Surgery. 1864. Beine a 5th edition, in one volume, of the 

previous work, largely revised by Dr P. H. Watson. 
6, On the Treatment of the Hsemorrhagic Diathesis. 1842. London, and 
Edinburgh Medical Journal. 

6. An Introductory Lecture on Sur^ry. Delivered 4th November 1840. 

7. Syllabus of Lectures on the Principles and Practice of Surgery. 1841. 

8. Introductorv Lecture on Pictorial Anatomy, delivered to the Students of 

the School of Design, and published at the request of the Honourable the 
Commissioners of the Board of Trustees for the Encouragement of 
Scottish Manufactures. 1842. 

9. On a Case of Inguinal Aneurism, in which the Patient committed Suicide 

by wound of the Tumour. Edinburgh Monthly Journal of Medical 
Science. 

10. Statement in Reply to Mr Syme's " Case of Stricture of the Urethra," 

treated by External Incision. Monthly Journal of Medical Science. 

11. Ununited Fracture treated by Subcutaneous Puncture. Monthly Journal 

of Medical Science. 1848. 

12. Address to the Graduates of the University of Edinburgh, 1st August 1856. 

Edinburgh Medical Journal. 

13. Address to the Medico-Chirurgical Society of Edinburgh, delivered on the 

occasion of his taking the Chair of the bociety, 17 th December 1856. 

14. Valedictory Address delivered at the Meeting of the Medico-Chirurgical 

Society, 15th December 1858. 

15. Address on Sureery, read at the Twenty-sixth Annual Meeting of the 

British Medical Association held in Edmburgh in July 1858. British 
Medical Journal, 28th Aupst 1858. 

16. Hora Harveiana. An Address delivered at the Annual Meeting of the 

Harveian Society in 1860. Edinburgh Medical Journal. 

17. Neuenahr. A New Spa on the Rhine. 1861. Edinburgh Medical Journal, 
• and largely reprinted. 



96 MEDICAL NEWS. [JULT 1804. 

18. On the Progress of Surgery in the isst Thirty Tears. Edinburgh Medical 

Journal. 

19. Medical Missions. An Address to Students introductory to a Course of 

Lectures on this Subject. 1849. 

20. Physiology in Harmony with the Bible. 1855. 2d Edition. 5th Thou- 

sand. 

21. The Day of Rest. Tract for Working Men and their Firesides. 

22. Labour Lightened, Not Lost. 

23. Abstinence, its Place and Power. A Lecture delivered before the Toung 

Men*8 Christian Association in Exeter Hall^ 31 st December 1856. 

24. Painless Operations in Surgery. North British Review, May 1847. 

25. Prostitution Considered in JRelation to its Cause and Cure. Edinburgh 

Medical Journal. 1859. 

26. Alcohol, iu Place and Power. 1857. 33d Thousand. 

27. Nephalism, the True Temperance of Scripturei Science, and Experience. 

28. An Appeal for the Sustentation Fund by Elders of the Free Church of 

Scothuid. 

29. Speech delivered at a Meeting for the Formation of an Association for 

Suppressing Drunkenness in Scotland, May 1850. 

30. Surgical Experience of Chloroform. 

31. History of Surgery. In the two last Editions of the Encydopssdia Bri- 

tannica. 

32. Numerous Speeches in Church Courts and elsewhere, on Topics connected 

with Religion and Social Improvements. 



PUBLICATIONS RECEIVED. 



▲rlidge,— The Mortality of Stoke-npon- Heryon, — Practical and PiKihoIogleal Re- 

TVent. By J. T. Arlidge, M.B. 1884. Bearches on the varioiu Fonns of Para- 

Amott,— Contribntions to Practical He^i- Ivsia. Bf Edward Meiyon, M.D., etc 

cine and Surgery. By James Amott, London, 1864. 

M.D., etc. London, 1864. Percyt^PhTsioIogical and Medicinal Pro- 

Basham, — Croonian Lectures for 1864 : The perties of the Yeratrnm Yiride. By 

Significance of Dropev as a Symiitom in Bamoel Percy, M.D., etc Philadelphia, 

Renal, Cardiac, and Palmonaiy Diseases. 1864. 

By W. R. Bairiiam, M.D., etc London, Pnrsell,~Rheaniatism, Gont, Sciatica, and 

1864. Neuralgia : their Rational Pathology and 

Chambers,— Lectures: chiefly Clinical By Successful Treatment By John PnneU, 

Thomas King Chambers, M.D., etc Lon- M.D., etc. London, 1864. 

don, 1864. Raddiife,— Lectures on EpUepsy, Pain, Par 

Da Costa,— Medical Diaffnosis, with Special ralysis, etc By C. Bland Raddiffo, M.D., 

Reference to Practical Medicine. By J. etc. London, 1864. 

M. Da Costa, M.D., etc Philadelphia, Swan,— Delineations of the Brain in Relation 

1864. to Yolnntaiy Motion. By Joseph Swan. 

Frits,— Etude dinique sur divers Symp- London, 1864. 

tomes spinaux obserr^ dans la Fi^vre Tilt, — A Handbook of Uterine Therapeutics. 

typholdc Par le Dr £. Frits. Paris, By Edward J. Tilt, M.D., etc Second 

1864. Edition. London, 1864. 

QtRYid,— The Essentials of Materia Medioa West,— Lectures on the Diseases of Women. 

and Therapeutics. ByA.B.Qanod, M.D., By Charles West, M.D., etc London, 

etc Second Edition. London, 1864. 1864. 

Jones,— Clinical Obserrations on Functional Wilde,— Ireland, Past and Present By Sir 

Nervous Disorders. By C. Handfield W. R. W. WUde. Dublin, 1864. 

Jones, M.B., etc London, 1864. Zander,- The Ophthalmoeoope : its Varietiea 

Lunacy,— Sixth Atinual Report of the Oen- and its Use Translated m>m the Qerman 

eral Board of Commissioners in Lunacy of Dr Adolf Zander. By R. B. Carter, 

for Scotland. Edinburgh, 1864. MJK.C.S.E, etc London^ 1864. 



)9art Jf^int 



ORIGINAL COMMUNICATIONa 

Article I. — Further ObservaHana an the Waxy cr Amyloid Form of 
Briahia Diaeaee. By T. Grainger Stewart, H.I)., F.R.aP., 
Pathologist to the Koyal Infirniaiy, Lecturer on General Patho- 
logy and Morbid Anatomy, Edinburgh, 

In February 1861, 1 published in this Journal certain views as to the 
symptoms which accompany the waxy or amyloid degeneration of 
tne kidney, one of the forms of Bright^s disease : symptoms which 
I conceivea to be so distinct and constant as to render it easy for 
us to distinguish during life between this and other fonns of renal 
affection. In this paper I propose to indicate the results of my 
obseiration of that aisease since the period of my former communi- 
cation, and the conclusions at which I have anriyed. Mesrhr all the 
cases have been observed in the Koyal Infirmary, and I beg to 
acknowledge my obligation to the physicians who nave kindly per- 
mitted me to publish them. 

The description which I then gave was the following : — '^ An 
individual who has long* suffered from wasting disease, such as 
scrofula, caries^ necrosis, or syphilis^ or who, though without pal- 
pable disease, is of a feeble constitution, feels an increasing weak- 
ness, and begins to pass large quantities of urine, and to drink 
largely. He is, contrary to his usual custom, obliged to rise 
repeatedly during the night to make water, and on each occasion 
passes a considerable quantity. The amount of urine varies from 
50 to upwards of 200 oz. daily, always bearing a relation to the 
amount of fluid drunk, generally nearly eaualling it in amount, or 
sometimes even exceeding it The feet and ankles become csdema- 
tons after a hard day's work, but return to their natural condition 
during the night's repose. In many cases there is observed a hard- 
ness and swemng in the hepatic and splenic regions, dependent on 
an increase of bulk of the liver and 8{)leen. The patient feels a 
constant lassitude and unfitness for exertion. His unne gradually 
becomes albuminous, and a few waxy or hyaline tubecasts are to 
be found in the very scanty sediment which it throws down. It is 
of low specific gravity — 1005 to 1015. The blood presents some 
peculiarities microscopically: the white corpuscles being somewhat 
mcreased in number, and the red presenting a flabby appearance, with 
a marked tendency to tail, — that is to say, instead of forming into 

VOL. X.— NO. II. *• 



98 DR aRAINQEK STEWART ON THE WAXY OR [AUQ. 

roaleaux, like healthy corpasclesy thej become stretched out into 
long, spindle-shaped bodies. The blood changes I have observed 
only when the degeneration affected the lymphatic or blood glands. 
The patient may continue in this state for months, or even years — 
may, indeed, undergo a temporary improvement — the liver and 
spleen becoming diminished in bulk, and the blood resuming a 
more healthy character; but, sooner or later, for the most part 
ascites or general dropsy gradually supervene, accompanied fre- 
quentljT by diarrhoea, which is at times found quite uncontrollable. 
The urine, now very albuminous, diminishes in quantity, so as at 
times to be almost or altogether suppressed; effusions into the 
serous cavities or severe bronchitis ensues ; the patient becomes 
exhausted and sinks, or drowsiness comes on, and the disease 
terminates amid coma and convulsions." 

Further experience has confirmed the opinions then expressed, 
and in all cases in which an autopsy revealed the lesion, and in 
which I had the opportunity of carefully examining the patients, 
I ascertained the existence of the symptoms which I have indi- 
cated. In support of my views I adduc^ in my former communi- 
cation twenty cases, in nine of which the existence of the lesion 
was ascertained by post-mortem inspection. In the present paper 
I shall complete the history of three of these, continue that of 
another to the present time, and give a summary of sixteen other 
cases, in several of which autopsies have been made. 

Case I. — ^A. M., shoemaker, »t. 33. His case was minutely described in 
the previous paper. Of a syphilitic constitution, he was, about four ^reani 
ago, ' . . - - . - - 

^th 




water, of low specific gravity. From his historv and the unnary ,,- , 

I ventured to anticipate the appearance of albumen in the urme. It was 
carefully tested, day oy day, ana, atfler a while, a trace of albumen appeared ; 
tliis gradually increased ; and afterwards fine hyaline tubecasts were occasion- 
ally seen in the urine. These symptoms had lasted for about nine months at 
the date of my former publication, and since that time they have steadily 
continued. The following notes were taken at the dates mentioned : — 

4ih Fdfruary 1861. — The Hver and spleen have further diminished in size. 
His appearance is somewhat less cachectic. For some days he has had a pain 
in the neighbourhood of the umbilicus, and along the maivin of the hver, 
aggravated on movement or on pressure, and after eating. The stools are of 
a dark colour, and contain some bright red blood. He has no piles. The 
amount of urine continues high, about 120 oz. daily. It is albuminous. 

Sth October 1861. — The patient again presented himself; his cachectic 
appearance is increased ; he comolains of a severe pain in the lumbar region, 
and along the spermatic cords. His renal symptoms continue unchanged, and 
the liver is still distinctly enlarged. 

Since that time he has frequently presented himself at the New Town Dispen- 
sary and elsewhere ; has repeatedly oeen an inmate of the Royal Infirmary; has 
been able occasionally to work at his occupation of shoemakmg, and has of late 
acted pretty constantly as cook to the Mid-Lothian Militia stationed at Dalkeith. 
The last note I have taken of his case was on 21st March 1864. He continues 
to make large quantities of water daily, usually upwards of 120 oz. It is still 
albuminous, but no tubecasts have been discoverea for some time. The hepatic 
dulness is diminished to about six inches ; the organ is still painful on pressure. 



1864.] AMYLOID FOBM OF BRIQUT'B DISEASE. 99 

He has no nansea, and liia boweb are regular; but on several occasiona lately 
he has had inteniie diarrhoea, sometimes bloody, and has vomited blood-coloured 
matters. His complexion is even darker than before, and his eyelids are more 
oedematons than I nave ever observed them. From some observations made for 
me by Mr Taylor, it appears that his temperature is somewhat lower than natural. 
Case II. — £. H., a Washerwoman, set. 43. This case was reported in the 

Erevious paper. She had been of intemperate habits, but was not known to 
ave had syphilis ; she had long-continued polyuria ; her urine was of low 
specific gravity, veijr albuminous, and contained hyaline casts. She had also 
a lesion of the aortic and mitral valves. She was dismissed from the Royal 
Infinnary in May 1860. In November of that year I found that her symptoms 
•Were not materially changed. She continued to make from 180 to 210 ojb. of 
urine daily. It was of low specific gravity ; it contained albumen and cast«. 
There was slight oedema ; the diarrhoea less intense than formerly ; the cardiac 
symptoms unchanged. Throughout the years 1861-62-63 I saw her frequently 
in St Cuthbert's Foorhouse, in the Koval Infirmarv, in the dispensary, and 
elsewhere. Her renal symptoms were little altered. A distinct aneurismal 
dilatation had gradually aeveloued itself; and a certain amount of oedema of the 
limbs occasionally appeared. When she was last in the Infirmary I had the 
opportunity, by the tmdness of Dr Laycock, of making the following notes : — 

20ik April 1864. — ^The skin is pale ; conjunctiva clear, slkrhtly oMematous. 
There is a good deal of congestion over the malar bones. The legs are oede- 
matons ; the tongue is clean. She has some difficult v in swallowing, particu- 
larly solids. Sickness follows eating, and she occasionally vomits. Vertical 
hepatic dulness in the right mamillary line measures about ^ve inches. The 
bowels are loose. She complains of pain in the left hypochondrium. She has 
occasional giddiness, and sleeps badly. Her pupils are equal. There is a double 
blowing. murmur at the apex of the nenrt, and at the base of the neck there is 
a very distinct aneurism. The urine is copious, exceeding on an average 100 
oz. daily. Its specific gravity is about 1008. It is of an acid reaction, contains 
much albumen, some phosphates, and epithelium and fpranular casts. 

6ih June, — ^Her dyspnoea, dropsy, and general debility gradually increased, 
until the 5th of June 1864, when she died. 

Auiopsyy 5S hours after death. — ^The body was well nourished. The right 
pleural cavity contained about half an ounce of clear serum. The left pleura 
was obliterated by old adhesions. Both lunffs were congested and oedematous ; 
in several parts there were small dense nodules, whose nature was not deter- 
mined. The pericardium contained a little fluid, and some lymph was deposited 
on both its layers. The heart was enlarged, weighed 84 ounces; it was 
fatty. The margins of the mitral valve were thickened. The aortic valves 
incompetent. The aorta was dilated, its coats sclerotic and atheromatous, and 
contained some calcareous plates. There were distinct dilatations in the course 
of the innominate and subclavian arteries. The liver weighed 3 lbs. 3^ ounces, 
was soft and fatty, and presented no reaction with iodine. Spleen weighed 3} 
ounces, and was not waxy. The right kidney was small, weiehine 4 ounces ; 
the capsule was adherent; the surface granular; the cortical substance was 
atrophied. The left weighed 6 ounces, was distinctly waxy and &tty, less 
atrophied; the capsule was also adherent. The Malpighian bodies, as well 
as the arteries of the cortex and of the cones, were in a state of waxy 
degeneration. 

Ca0b III. — £. B., a bricklayer's labourer, aged 33. His case was recorded 
in the previous paper. Of a syphilitic constitution, he made a large quantity 
of water, upwards of one hundred ounces daily, highly albuminous, of low 
specific gravity, and containing a few waxy casts. He was dismissed from the 
Infirmary on tne 30th of Apnl 1860. The following notes indicate his after 
history : — 

7th April 1861. — His general appearance is better than it had been last year. 
He states that he is quite well, but that the daily amount of urine has not 
diminished. It is highly albuminous, of low specific gravity, and contains casts. 



100 DR QRAINGEB STEWART ON THE WAXT OR [AUG. 

His tongue is clean ; his appetite good ; his bowels are moved twice a-day. 
The liyer is much enlarged, measures eight inches vertically, and extends con- 
siderably across the epigastrium to the left side. The spleen is also enlarged. 
The blood contains an excess of white corpuscles. Expiration is harsh and 
prolonged at the apices of both lungs. The heart-sounds are altered in tone, 
out not of a blowing character. * 

13th Augutt 1862.-'The patient again presented himself. He is more emaci- 
ated. States that from increasing debility he has been unable to work for a 
month past. He still makes large quantities of urine, which is albuminous, 
but not so intensely as before. It deposits a sediment containing hyaline tube- 
casts, with oU-grannles here and there arranged in groups, as ifresultinff from 
disintegration of cells. There has been no oropsy of late. The liver, Uioug^ 
still enlarged, is decidedly diminished since last report. He complains much 
of his breathing. 

22d September 1863. — He complains much of difficulty of breathing, and of 
cough and headache when he attempts to stoop; he has also dropsy; and 
from all these symptoms feels himself unable to follow his usual work. The 
amount of urine is still large. He is obliged to rise three or four times evety 
night in order to micturate. The urine is albuminous, and contains casts. 
He entered the Infirmary, and under the care of Dr Sanders improved, so as 
to be able to go out, and for a time pursue his usual avocations ; but in 
November he again presented himself, complaining of a further aggravation 
of his symptoms. He died soon after admission, in November 1863, and his 
body presented the following post-mortem appearances : — 

The body was somewhat emaciated. The neart was enlarged ; its left side 
was much hypertrophied. The aortic valves were competent ; but at the base 
of one of the segments there was a calcareous mass. The aorta was very 
atheromatous. The lun^s were very oedematous ; the bronchi were congested 
and full of mucus. The liver was about the natural size. On its surface were 
a number of nodules and cicatrices. At the bottom of some of the latter, 
nodules of a pale colour were visible. On section, numerous nodules were 
found scattered throughout the organ ; they were pale, dense, and had an 
appearance exactly resembling bees- wax ; their structure was much denser than 
that of the surrounding tissue. In some nodules there were streaks of fibrous 
tissue throughout the substance and round the margin, and the greater the 
proportion of that tissue the deeper were the cicatrices. In the nodules 
elevated above the surface there were no such streaks, or very few. In those 
situated at the bottom of deep cicatrices, the fibrous element was abundant, or 
even in excess of the glandular. On applying iodine to these masses, the whole 
of the waxy-looking material assumed the brownish red colour characteristic 
of the amyloid defeneration, but the fibrous streaks simply assumed a yellow 
tinge. Microscopically, the masses were found to present exactly the char- 
acters of ordinary amyloid hepatic cells. They were composed entirely of these 
cells, enlarged, transparent, and finely granular. In some parts the ceUular 
elements were broken down, and a finely grannlar material containing some 
oil-globules was present. The fibrous tissue in the masses presented the 
ordinary characters of connective-tissue ; and where it was most abundant the 
cells were most atrophied. Throughout the rest of ~the organ the cells were 
little affected with the waxy deeeneration, but some of the small vessels showed 
it distinctly. The fibrous bands were seen passing into the tissues round the 
cicatrices and nodules. The capsule of Gbsson was thickened in some parts, 
and on applying the iodine externally to the cicatrices no reaction was observed. 
The spleen contained one cicatrised mass, which presented no reaction with 
iodine. The kidneys were somewhat contracted in the cortical substance, and 
presented a very well-marked instance of the amyloid degeneration of the 
vessels and Malpighian bodies. There was some degree of amyloid degenera- 
tion of the villi of the small intestine ; the bowels were otherwise natural. 
The prepuce presented traces of the old s;^hilis, and it had been previously 
ascertained that there were numerous syphilitic ulcerations in the throat. 



1864.] AMYLOID FORM OF BBIOHT's DISEASE. 101 

Case IV . — J . M. , brashmaker, aged 83. His case was recorded in the previous 
paper. Of a syphilitic constitation, he exhibited distinct traces of the cachexia. 
Willie nnder OMervation, he passed from 60 to 80 ounces of urine daily, of low 
specific gravity, albuminous, with hyaline tubeca8ts,and containinff here and there 
a fistty cell. He was dismissed from the Infirmary about the middle of August 
1860, and for a year afterwards I saw him occasionally. He always retained the 
cachectic appearance, and continued to make large cj^uantities of urine. Until 
the end of October 1861 he was going about attending to his work, but sud- 
denly his urine diminished in quantity, and became bl^v, and on the follow- 
ing day he was seixed with convulsions. These continued for some da^s. He 
was removed to the Infirmary, where he died on 5th November. In the mtervals 
of his fits he was conscious, though unable to speak. 

On post-mortem examination there was found syphilitic necrosis of the 
cranial bones, and other evidences of constitutional syphilb. The liver was 
large and distinctly waxy ; the spleen presented the degeneration in a slight 
degree ; the kidneys were somewnat contracted, firm, and presented an exqui- 
site specimen of the amyloid degeneration of the vessels and Malpighian bodies. 

In these four cases we have a continuation of the history of this disease in 
cases previously published. The following cases are new. 

Case Y. — ^J. M., labourer, aged 18, admitted to the Royal Infirmary, under 
the care of Dr Bennett, 13th September 1861. He stated that six weeks pre- 
vious to admission he caught cold, had cough, with frothy expectoration, and 
soon afterwards that he noticed that he was passing more water than usual. 
Had frequently to get up durins the night to empty his bladder. About a 
month later his feet began to swell. 

On admission, the heart-sounds were normal. There were the ordinary signs 
and symptoms of bronchitis. There was no dropsv. The skin was cool and 
moist. There was lumbar pain. The urine was pale, very copious ; of specific 

Savity 1012; highly albuminous; contained granular and fatty tubecasts. 
e had great thurst. The bowels were constipated. 

The amount of urine varied between 3d and 15th October from 75 to 122 
ounces. Only on three days was it below 100 ounces. Throughout that month 
the (quantity continued uirge^ though on some days it was considerably 
diminished, and it was almost mvariablv in excess of the fluids drunk. The 
pulmonary symptoms rapidly increased in severity. The upper half of one 
lung became distinctlv dull, while the bronchial affection increased. There 
was some degree of dropsy. The blood contained fully double the natural 
proportions of white corpuscles. 

During November and December the daily quantity of urine gradually 
diminished. The albumen did not diminish. The casts became less fatty. 
General dropsy set in. This symptom became so distressing, that, on 10th June, 
acupuncture was employed for the relief of the dropsy. At the same time the 
pulmonary symptoms steadily increased, and the patient died on 13th January. 

On post-mortem examination, there was general dropsv of cellular tissue 
and serous cavities. The heart was somewhat hypertropbied. Both pleursB 
were adherent. The lungs were oadematous, and contained distinct traces of 
tubercle. The kidney capsule was adherent; the surface granukir. The 
cortical substance somewhat atrophied. Many of the tubules were filled 
with finely granular fatty matter. The spleen was firm ; the intestines were 
cedematous. On adding a solution of iodine, many of the arteries and Mal- 
piehian bodies assumed a reddish orange colour, and on the fmrther addition of 
dilute stdphuric acid became reddish purple. There was slight waxy degenera- 
tion of the liver, spleen, and of portions of the intestines. 

Case VI.— I. C.^t. 16, a servant, admitted to Ward XT., 27th February 1861, 
under the care of br Laycock. She had in the year 1860 been affected with 
phthisis pulmonalis, and had somewhat improved. After I had lost sight of 
ner she observed that she had occasion to get up several times every night to 
make water, and that each time she made a large quantity. About January 
she was exposed to cold and wet, and noticed that her feet and ankles swelled, 



102 DR GRAINGER RTEWART ON THE WAXT OR [AUG, 

and her urine became diminished in quantity. She had also some lumbar 
pain and diarrhoea, and on this account entered the Infirmary. 

On her admission I had an opportunity of examining her, and found the 
signs of phthisis considerably developed. She looked anaemic. Her appetite 
was bad. She freauently vomited. Her bowels were very loose. The amount 
of her urine coula not be determined on account of the diarrhoea. It was 
highly albuminous; specific gravity 1030. Contained hyaline casts. The 
liver and spleen were enlarged. The blood contained an unusual number of 
white corpuscles. There was considerable general dropsy, and she died a few 
days after admission. 

AtUopsy. — The lungs were found to contain large quantities of tubercle, and 
on the intestines there were numerous irregular tubercular ulcers. The hver, 
kidneys, and spleen were found to be large and waxy. The Malpishian bodies 
and small arteries of the kidneys assumed a reddish purple colour on the 
addition of iodine and sulphuric acid. Many of the hepatic cells and the 
Malpighian bodies of the spleen presented the same reaction. 

Case YII. — .J. C, set. 21, a miner, was admitted, under the care of Dr 
Haldane, into the Royal Infirmary, in January 18G4. He was of stunted 
growth. He had worked underground since he was seven years of ase. At 
the age of sixteen he had pneumonia, and ever afterwards was breathless and 
liable to colds. He used to notice that he had to rise during the night to make 
water, and was often interrupted at his work from the same cause. Two 
months before admission he was exposed to cold and wet, and became drop- 
sical. His urine diminished in quantity ; its specific gravity was 1015, albu- 
minous, and contained some casts. He died exhausted, partly by the renal 
and partly by pulmonary affection. 

Autopsy^ forty-two hours after death. The body was greatly emaciated. 
The lungs contained tubercle and carbonaceous matter. There were some 
vomicsB towards the apices. The heart was dilated. The liver normal The 
spleen presented amyloid degeneration of the Malpighian bodies. The kidneys 
were ofgood size ; many of the tubercles filled with fatty granules and exudfa- 
tion. Tne small arteries and Malpighian bodies presented a translucent 
appearance, and assumed a blue colour on the addition of iodine and sulphuric 
acid. The villi of the small intestine also presented this degeneration. 

Case VIII.— J. N., at. 32, Ward VII., under the care of Dr Haldane, in the 
Royal Infirmary. Examined 25th January 1864. 

f^ourteen years ago, when the patient was eighteen years of a^e, he had chancre, 
and other signs of constitutional syphilis. These syphilitic symptoms con- 
tinued to recur at intervals for a long time. Six years ago, having been 
exposed to cold and wet, he had what seems from his description to have been 
an attack of acute renal dropsy. From this he recovered. Has since had pains 
in the tibia, worst at night ; in the epigastrium, and in the region of the kidneys. 
Towards the end of last year he observed that he was obliged to get up several 
times every night and make water, and that on each occasion he made a con- 
siderable quantity. He estimated the amount to be about 160 ounces. This 
has continued to the present time. 

On admission, his liver was found enlarged. In the line of the nipple it 
measured 7 inches vertically; in the middle line 5i. The spleen was also 
enlarged ; measured 41 inches vertically, and 6 inches across. The blood con- 
tained an excess of white corpuscles, and the red did not form rouleaux, but 
irregular clumps; they had a tendency to tail. The toneue was loaded in 
the centre, furred at the edges. The appetite was good, but some sickness 
and vomiting followed every meal. The bowels were natural. The heart 
sounds were normal. Pulse about 92 per minute. There was some crepi- 
tation heard at the bases of both lungs, and at the apex of the right. There 
was pain on pressure over the kidneys. The urine varied in amount, from 
90 to 130 or 150 oz. ; was pale, of low specific gravity, contained much 
albumen, but no tubecasts could be found. There was also enlargement of the 
right testicle, and dropsy of the left tunica vaginalis. There were numerous 



1864.] AMYLOID FORM OF BRIOHT'S DI8EA8R. 103 

muJl periosteal sweUings over both tibue. There was also a tendency to 
swelling of the feet in the evening, but not to any great extent. There were 
also occasional attacks of epistaxis, and of h»morrhii^e from the bowels, and a 
purpuric condition of the skin of the lower extremities. The gums were also 
swollen and spongy. 

I2lh AprU. — l^der a general tonic treatment, the patient has in so far im- 

S roved, bat he continues to present the sjrmptoms characteristic of waxy 
exeneration of the kidneys, liver, and spleen, lie was dismissed relieved. 

Case IX. — A. M., a seaman, »t. 34, admitted to Patents ward, under the 
care of Dr Laycock, 6th February 1864. In his profession of seaman he has 
travelled much in foreign countries. Was never an intemperate man, though 
he sometimes took a week's debauch on getting ashore. He never had syphilis, 
but once, sevwal years ago, had some ulcers m the throat. Four years a^o, 
while in India, he was ill of inflammation of the liver, at least an inflammation 
at the hejMitic region, unaccompanied by jaundice. Since that time he has 
been working on the Bumtislana ferry steamer, and was much exposed to cold 
and wet. He noticed that his feet tended to sweU slightly, particularly 
towards evening, and about nine months ago (last August) he observed that he 
was compelled to leave his bed several times every night in order to micturate, 
and that each time he made a considerable quantity. This was before the 
dropsy be^an. Last October he caught cold, bad cough and expectoration, and 
about Christmas his feet and legs swelled considerably, and he noticed that his 
abdomen was remarkably prominent and hard. These symptoms increasing, 
he was unable to work, ana was admitted to the Infirmary 6tn February. 

On admission, he was a stout-built man, somewhat pale, but Vith numerous 
distended capillaries over the maJar bones. He had an incipient arcus senilis. 
His breath was short; but the respiratorv and circulatory sounds were normal. 
The gastro-mtestinal system was normal ; but the liver was much enlarged, 
measuring about eight inches vertically, and extending over on the epigastrium. 
The spleen also seemed enlai^ed. The blood contained a slight excess of 
white corpuscles, and the red had a somewhat flabby appearance. There was 
some degree of ascites. There was no lumbar pain even on pressure. The daily 
quantity of urine was about 120 ounces. Its specific gravity was about 1013 ; 
its colour pale amber ; its reaction acid ; it contained a good deal of albumen, 
and a few finely granular and hyaline tnbecasts. 

12th AprU.-— Since he has been under treatment, his general health has im- 
proved. The dropsy has for the most part disappeared, but the characters of 
the urine have remamed unaltered. He was dismissed relieved. 

Casb X.— £. D., set. 35, a bookbinder, first examined 7th March 1861. 
This patient had contracted syphilis fifteen years before he came under my 
observation. Since that time he has suffered from various const itutiontd 
symptoms, eruptions, nodes, tic, etc. At the time he was under my care he 
liad a pustular syphilitic eruption on his face. During the year preceding he 
had observed that he was obliged to get out of bed several times each night in 
order to make water, and that he m^e a considerable quantity on each occa- 
sion. At the same time he observed that his feet were swollen at night, but 
the swelling had subsided in the morning. The urine varied in amount from 
65 to 150 oz. per diem. It was highly albuminous, and contained a few hyaline 
casts. This large quantity of urine continued to be passed daily for several 
months during which he was under observation. The liver and spleen were 
natural. 

The patient having left Edinburgh, I lost sight of him ; but the symptoms of 
his case were so distinctly those of amyloid degeneration, that I nave no 
hesitation in including him in this category. 

Case XI. — J. M., et. 36, a labourer, was admitted to the Hoyal Infirmary, 
under the care of Dr Haldane, in April 1864. He had led an irregular li&, 
had been a soldier, and was believed oy his friends to have been the subject of 
syphilis. About two years before admission he was observed to make large 
quantities of water, and at a time at which he exhibited no other symptoms of 



104 DB GRAINGER STEWART ON THE WAXT OR [AUG. 

illneiw, his frequent micturition had become a standing joke in his family 
circle. About six months before admission he became dropsical, and exces- 
sively intemperate. About the middle of April he was exposed to cold and 
wet, and was seized with rigors, following upon which was a severe pneumonia, 
from which he died. 

AtUcpty. — His body was examined eighteen hours after death. The heart 
was normal. The right lung was pneumonic throughout, some portions of 
it in a state of gre^ hepatization, otners less advanced. The left lung was 
adherent to the diaphragm at the base, and in its lower lobe contained a 
cicatrix. The liver weigned 5 lbs. 10 ounces, was waxv and fatty. Spleen 
waxy, weighed upwards of 1 lb. The kidnevs were both enlarge^ the ri^ ht 
weighed 11 ounces, and the left 9 ounces. Both, of them presented exquisite 
examples of the amvloid degeneration of the vessels ana Malpighian tufts. 
There was also marked fatty degeneration of the epithelium in the tubules, 
and while the whole organs were increased in size, the cortical substance was 
relatively diminished. The surface was granular. There was abundance of 
fat throughout the bodv, particularly in the omentum and mesentery. The 
intestines tore off from tlie mesentery with the greatest ease. Its vessels were 
found to be in a state of amyloid degeneration. The villi and minute arteries 
of the small intestine presented exquisite examples of the degeneration. 
Brain congested. Serous effusion on its surface ana under its membrane. 

Case XII. — M. R., set. 44, was admitted to the Roval Infirmary, under the 
care of Dr Sanders, 26th May 1864. She was a field-worker, and latterly 
a washerwoman ; had generally been healthy, but for two months before admis- 
sion had been* out of nealth; her breathing being embarrassed, her appetite 
poor, bowels loose, urine copious. A fortnight before admission dropsy had 
appeared. The quantity of urine was upwards of 80 ounces daily ; it was pale, 
of specific gravity 1011 ; contained albumen, and no tubecasts. In the hospital 
these symptoms continued, and she died exhausted on 10th June. 

Autopsy^ seventy-two hours after death. The body was well nourished. 
The heart was natural. Aortic valves somewhat thickened. Arch of the aorta 
was very atheromatous, and contained some calcareous plates. The lungs were 
oedematouB. Near the root of the lefl there were some tubercle-like deposits. 
Bronchial glands were enlarged, one of them suppurating. The liver was some- 
what waxy ; presented some syphilitic cicatrices. The spleen was intensely 
waxy, and throughout its substance there were a number of small abscesses. The 
pus which they contained was normal, and presented no reaction with iodine. 
The abscesses were scattered throughout the substance. The capule was 
thickened, but not of dense structure ; it was adherent to neighbounng parts. 
The kidneys were atrophied, and intensely waxv, some of the tubes as well as all 
the arteries and Malpighian tufts presenting the ordinary reaction with iodine. 
Connected with the uterus was a number of fibrous tumours. The ovaries 
were fibrous. The intestinal canal was also in a state of waxy or amyloid 
degeneration ; its viUi and small vessels presenting the reaction very distinctly. 

Case XIII.— A. L., set. 26, admitted 16th May 1864, to the Royal Infirmary, 
under the care of Professor Bennett. The patient was a sempstress, un- 
married. She stated that she had been quite healthy until two years ago 
(May 1862), when she had acute rheumatism, and since then had never been 
well. Her feet and legs, and afterwards her abdomen, swelled, and she was 
obliged frequently to get up during the niffht to make water. On admission, 
the heart and lungs were normal, face swollen, skin pale. The urine was large 
in quantitv, varying from 70 to 100 ounces daily, of low specific gravity, and 
of pale colour; it contained abundance of albumen, and some tubecasts. She 
also had severe diarrhoea, and occasional sickness and vomiting. The dropsy 
gradually increased, and she died exhausted on the 29th of June. 

AuUipty. — The face and upper parts of the body were very oedematons. 
The abdomen was somewhat distended with fluid, and the legs pitted slightly 
on pressure. The heart was natural. The left pleural sac was obliterated by 
old adhesions, and in the right there was considerable effusion. The lungs 



1864.] AMTLOIU FORM OF B11IGHT*8 DI8BA6E. 105 

were congested and ^ematous. The liver was connected with neighbourinff 
parte by a number of old adhesions, and on its surface there were several 
cicatrices. The whole organ was fatty and waxy ; the vessels exhibiting a 
distinct reaction with iodine. The cicatrices were composed of fibrous tissue, 
with numerous vessels in a state of waxy or amyloid degeneration. The 
spleen weighed 8 ounces. Some of its vessels and Malpighian bodies were 
waxy. The kidnevs weighed 6| ounces each, were fatty and waxy, granular 
on the surface; the cortical substance partially atrophied. Many of the 
tubules were filled with granular exudation, and the vessels and Malpighian 
bodies presented the appearance of the waxy degeneration and a marked 
reaction with iodine. Some of the smaller vessels were also fatty. The intes- 
tines were waxy throughout their whole extent, and presented no trace of 
ulceration. In the lai^ intestine rings of pigmentary deposit surrounded 
many of the solitary folhcles. 

Cabb XIV.— a. C, »t. 30, was admitted dOth May 1864, to the Royal 
Infirmary, under the care of Dr Sanders. The patient stated that she enjoyed 
ffood health till within four weeks of her admission, but for some months 
before had observed that she passed a lar^r quantitv of urine than natural. 
She was obliged to get up several times during tne uignt in order to micturate. 
She had a little dropsy, but it disappeared on the occurrence ot diarrhcea 
a few weeks before admission. Her urine was pale, of specific gravity 1010, 
contained much albumen ; was always upwards of 60 ounces daily, although 
she was affected at the same time with severe diarrhoea. She had frequent 
vomiting, and gradually became exhausted and died on 28th June. There was 
a distinct history of scrofula in her fiimily. There was no positive evidence 
of syphilis, but she had the cachectic appearance, and comphuned much of 
pains in her bones. 

Autopty, — The body was somewhat emaciated. The heart and lungs were 
natural. Bronchi contained much mnco-purulent fluid. The liver was large, 
weighed 4 lbs. 6 ounces ; was bound to the diaphragm by numerous old adhe- 
sions. It was fatty and waxy throughout ; both the vessels and cells were waxy. 
The spleen weighed 1 lb. 1 uunce ; was intensely waxy. It was adherent to the 
diaphragm and neighbouring parts. The kidneys were both enlarged, the left 
weighme 9 1 ounces, the right 1\ ounces. Both were intensely waxy. The 
vessels both in the cortical and conical substance, and the basement membranes 
of the tubes, presenting the amyloid reaction. In the right there were some 
tubercular-like masses, with corresponding cicatrices on the surface. The 
intestines were in a state of waxy degeneration. There was a small super- 
numerary spleen, which was also intensely waxv. 

Case Xv. — A. F., set. 22, a hawker, resiaing in Fountainbridge. She 
came under my care in March 1862, complaining of cough and oedema of 
her feet. I found that for three years she had nad a cough, accompanied 
with expectoration and shortness of breath. Her chest gave signs of phthisis 
pulmonalis, but of a very chronic character. There was comparative dulness 
at the right apex; the respiration was indistinct, and accompsnied by fine 
crepitation in tne same region. The respiration at the left apex was clear, but 
the cardiac sounds were ver^ distinctly propagated. The liver was enlarged, 
and extended across the epigastrium. Its vertical dulness in the mamillary 
line measured 5 inches. The spleen was not enlarged. The quantity of 
water was much above the normal, ranging from 80 to 130 oa. per diem. It 
was of a pale amber colour, slightly albuminous. No casts were found. The 
skin was dry ; the appetite very fitful. 

Since 18^ the patient has l>een under observation, and has sometimes im- 
proved in strength under tonic treatment, and at times suffered accessions of 
ner disease. She has continued to pass large quantities of urine, which has at 
tiroes been albuminous, at others not. She has also had hemoptysis, and her 
chest symptoms are increasing in severity. 

When sne was lately an inmate of the Royal Infirmary, the following was 
her condition :~Skin pale; respiration harsh; slight dulness under right 

VOL. X. — NO. u. o 



106 DB 6BAIKQEB STEWART ON THE WAXY OR [AUG. 

clavicle; appetite irregular; urine about 105 oz. daily, of a pale yellow colour, 
ftpectfic gravity ranging from 1005 to 1012, of acid reaction, contained much 
albumen, much epithelium, and no sugar ; no tubecasts were found. In thia 
condition she continued when last seen. 

Case XVL — Mr , a gentleman of independent fortune, had, at about the 

affe of 14, an abscess in the rifht side, near the hepatic region, but the source 
of which was not ascertained. He after this was healthy, vigorous, a keen 
sportsman ; but at the age of 31 he began to complain of gripine pains and 
severe diarrhoea. On examination it was found he was passing large quan- 
tities of urine. He was frequently obliged to get up during the night, ib 
order to micturate. The urine was quite clear, very pale, of specific gravity 
1008, containing albumen in considerable quantity. The casts were few, hya- 
line, with occasional fatty cells. The appetite was capricious ; the stools were 
pale, and of an offensive odour. The liver was not enkirged. His symptoms 
gradually increased, and he died about the age of 32. 

No autopsy was permitted ; but his symptoms were so distinct as to incline 
me decidedly to reckon this a ease of waxy degeneration of the kidney and 
intestine. 

The following case illustrates the apparent curability of this 
degeneration. The patient exhibited all the symptoms of the 
degeneration of the organ, but these symptoms gradually disap- 
peared: — 

Casb XVn. Mr M., a gentleman, sot. 21, resident iu Edinburgh, has been 
under my care for some months. 

Some years ago he fell into a state of delicate health. His appetite became 
poor, and he became subject to occasional hemorrhages, from the nose and 
other sources. His liver was greatly enlarged, eitending downwards to the 
umbilicus; the quantity of urine mcreased to a marked extent, and was 
albuminous ; his bowels were very irr^^r ; and his general health much im- 
paired. Under a course of iron, and of iodide of potassium, his general health 
improved, the liver diminished in sice, and the urine became free of albumen. 
For about a year past no albumen has been observed ; and his strength has 
become such as to enable him to resume his ordinary employment, and to 
work at it regularly durine the past winter. The liver continues, even now, 
somewhat enlarged, and the cachectic appearance continues, but the urinary 
symptoms have very markedly improved. 

The following case is of interest, as one possibly of amyloid 
degeneration of the kidneys, though the disease is not in the mean- 
time distinctly defined : — 

Case XVIII.— W. L., a brassfounder, set, 53, was admitted to the Royal 
Infirmary in March 1864, under the care of Dr Haldane. He states that he 
never had any venereal disease, excepting an attack of gonorrhoea, thirty years 
ago. He has been tolerably steady, but, while working in London, was 
accustomed to consume a good deal of beer. He noticea for some months 
past that he has been obliged to rise during the night to make water ; and that 
if he was much confined his feet swelled slightly. In the end of February he 
vomited some clotted blood, and his stools were black. 

On admission, he was anasmic ; the skin and sclerotic slightly icteric ; the 
eyelids were distmctly oedematous; the tongue was furred ; the appetite poor ; 
the bowels constipated. The liver was of normal size ; the spleen measured 
3 inches vertically, and 44 inches across. The red corpuscles of the blood 
were pale and flabby, and the white were not increased in number. The 
heart and lungs were normal. The urine was, on the day following his 
admission, 60 oz., of specific gravity 1015 ; of a straw colour ; acid reaction ; 
contained a slight mucous cloud ; otnerwise normal. The following day, how- 



1864.] AMYLOID FORM OF BRIOHT'S DISEASE. 107 

ever, he made more water, about 100 os., of specific grayity 1010; and he 
has continued ever smce to pass that amount at least, every day. Albumen 
has not been observed. His general health has somewhat improved; but a 
lumbtf pain has appeared, the oedema of the eyelids is undiminished, and his 
mrinary symptoms continue. I mentioned in my former paper that I had 
anticipated in one case the appearance of the albumen in the urine, judging 
from the symptoms that an early stage of amyloid degeneration was present. 
It seems not unprobable that in this case also we have the early symptoms, 
which may erelong develop themselves into something more important. 

Haying thus sketched the cases which I have recently obeervedy 
I shall now proceed to speak of each of the symptoms in saccession, 
to indicate tneir importance. * 

The Quantity of Urme. — It will be observed that in all the cases 
I have mentioned, this is a prominent symptom. The increased 

Joantity of nrine being marked throughout the whole cooroe of the 
isease; a diminution below the natural standard occurring only 
towards the end of the case, or under accidental influences. In 
many cases I hare found that the patient was not aware of the 
increased flow of the urine, and onl^ indicated it when he stated 
that he had to get up frequently during the night to make water, 
and that at each time he made a natural or excessive quantity ; ana 
thus I have found it necessary to ask them, not only whether they 
have observed that they made an excessive amount of water, but 
whether calls to micturition had disturbed them during the night. 

The pathological anatomy of the disease seems to me to account 
very well for the changes in the amount of thiB secretion. The 
earliest manifestation of the degeneration is commonly in the trans- 
verse muscular fibres of the small arteries, and if these fibres are 
degenerated, it is reasonable to suppose that they are paralyzed, and 
so the regulating influence lost, ana a congestion of the Malpighian 
bodies results. Unquestionably, when the defeneration has advanced, 
it diminishes the lumen of the arteries, and so must diminish the 
supply of blood ; but other parts may act more vigorously, and more 
than compensate for the aisadvantage. In the extreme stage a 
diminution actually does take place, and this perhaps coincidently, 
as I previously suggested, with exudation into the uriniferous tubules, 
as well as extreme degeneration of the arteries. This view, which 
I maintained on a former occasion, was opposed, on the ground 
that, in proportion as the degeneration of the arteries advanced, 
their calibre became diminished, and, as a necessary consequence, 
a smaller quantity of blood than natural could be transmitted to 
the vessels beyond ; and if it were true that the watery part of the 
urine was mainly derived from the Malpighian tufts, it seemed very 
strange that the secretion should be increased, for it was precisely 
in the vessels forming these tufts that the degeneration was found 
most advanced ; and it was maintained that the only way in which 
the increase of urine could be accounted for was by a reference to 
Virchow's and Beale's discoveries as to the circulation in the kidney. 
These observers show that a considerable quantity of blood passes 



108 DR GRAINaER STEWART ON THE WAXT OR [AUG. 

directly irom the branches of the renal artery into the vasa recta of 
the medullary portion, and from thence into the capillaries, without 
passing into the cortical portion at all. From this it is evident that 
not only in the waxy degeneration, but in other forms of disease of 
the kidney, where there is an obstruction of the paBsase of blood 
through the vessels of the cortical portion, an increased collateral 
nressure would be exerted on the vessels oi the medullary portion, 
nrom which, in conseauence, an increased flow of watery urine would 
take place, and the whole quantity passed might be above, or, at 
least, not below the average. But the amount of blood sent directly 
to the medullary portion is very much less than that sent to the 
cortical substance, and no one can conceive that a shutting off of 
the latter from functional activity could be more than compensated 
by increased activity in the former. To say that a set of vessels, 
not amounting to more than one-fifth of another set, are capable of 
performing all their functions, seems to me extremely unsound, and, 
especially in this case, untenable, seeing that the vasa recta of the 
medullary portion are themselves very often the seat of this degene- 
ration, ana ^et the poljniria is present. The explanation seems 
quite inapplicable to this form of disease. Besiaes, it is by no 
means proved that merelv the amount of blood in a vessel bears 
relation to the amount oi fluid transuding through its walls ; the 
state of these walls themselves may probably influence these transu- 
dations in a manner and to a degree that we by no means under- 
stand. I do not wish to commit myself to any theorjr on this point, 
but it seems to me that the probabilities are more in favour of my 
explanation than of the other. An increase of thirst and of drinking 
cannot be regarded as the essential cause of the polyuria, seeing that 
in some cases I distinctly ascertained that the amount of urine was 
equal to, or even surpassed, the total amount of fluids consumed. 

Character of the Urine. — The pale colour, and low specific gravity, 
and the presence of albumen, do not require special notice. The 
quantity of urea I hope soon to make the subject of special inquiry. 
The Tubecasts, — ^In the amyloid degeneration we may meet with 
tubecasts of various kinds, the delicate transparent casts, which 
were formerly called waxy, and are now better termed hyaline ; 
these hyaline casts with occasional epithelial cells in a state of 
fatty degeneration enclosed in their substance, others with a larger 
number of fatty cells, and occasionally finely or coarsely granular 
casts. Occasionally we see casts containing individual cells in a 
state of amyloid degeneration, and presenting its peculiar reaction. 
The occurrence of casts, such as these last mentioned, and which 
may be termed the amyloid casts, would of course establish the 
diagnosis of amyloid degeneration of the kidney ; but none of the 
others aflbrd any special evidence on one side or other, for they 
occur in all forms of Bright's disease. Thus, the hyaline casts con- 
stantly occur in the late stages of that degeneration which follows 
upon acute nephritis, and are thus evidently derived from uriniferous 



18^.] AMYLOID FORM OP BRI0HT*8 DISEASE. 109 

tabnles which have been denuded of epithelium. Those which 
contain a few cells in a state of fatty degeneration, and derived from 
tabtdes whose cells have in so far been destroyed, but in which some 
still remain) and those which present the granular appearance^ are 
either composed of cells completely broken down, or of exudative 
matter in a state of incipient degeneration. If we trace a case 
of acute nephritis, we find in succession bloody and epithelial casts, 
granular casts, fatty casts, the amount of fatty cells gradually dimin- 
ishing, and ultimatelv hyaline casts. In the waxy or amyloid 
degeneration we see the same casts, but appearing in the reversed 
order. Many varieties of conditions of the tubules exist in these 
cases of amyloid degeneration, and consequently we have a corre- 
sponding variety of casts. In the gouty kidney we also meet with 
the same forms ; so that in no case can we positively conclude, unless 
where we have bloody or amyloid casts, as to the nature of the dis- 
ease from their indications. It is true, that in the earlv stage of the 
amyloid de^neration hyaline casts prevail ; but that, if unsupported 
by other evidence, cannot enable us to establish a diagnosis. Casts 
are formed by the coagulation of an exudation, or transudation 
poured out mm the bloodvessels into tubules. This exudation, 
of course, encloses within it the epithelial or other elements which 
may be present within the tubes, and when the current of urine 
carries away the exudation, it, of course, carries also the enclosed 
matters. Thus, if it be poured out into a tubule denuded of 
epithelium, hyaline casts result: if into one full of cells, cell 
tubecasts result ; if into one witn a few cells, corresponding casts 
are formed. It is much to be regretted that the term '^waxy 
casts" has so often been applied to the hyaline, for it has led 
many to imagine a relationship between these casts and waxy 
degeneration. The name is one which can only deceive, and should 
be abandoned. 

Dropgy. — In some cases this symptom never appears at all ; but, 
in the majority of instances, it occurs as a serious concomitant late 
in the disease, and in many at earlier stages. The patient com- 
plains that towards evening his bo3ts become tight, though they 
fitted him comfortably in the morning. This state may continue 
for months, and only very gradually increase so as to become 
serious. Very commonly it first becomes severe in conseauence of 
an intercurrent attack of acute nephritis. I do not think that it 
consists with the object of the present paper to enter into the causes 
or mechanism of dropsy ; we shall therefore not say more on this topic. 

Diarrhaoa. — This is a very common, and frequently veiy serious 
symptom in cases of waxy degeneration. It appears to occur in all 
cases where the mucous membrane of the intestine has been affected. 
In the " Cellular Pathologic," Virchow speaks of the association of 
this symptom with the degeneration of the intestine as an estab- 
lished fact, and it will be observed that the cases I record confirm 
his observation. 

Temperature. — ^I am indebted to my friend Mr Herbert Taylor 



110 DR QBAIN6EK STEWART ON THE WAXT OR [AUQ. 

for a few observationB on the temperature of A. M.^ Case 1, from 
which it appears that a constant diminution by a few degrees 
exifltedy but much more extensive observation would be required to 
enable us to arrive at anj general conclusion on this subject. 

The CackeaAa,^ and the &ate of the Liver and the Blood. — ^In many 
of the cases it will be observed a peculiar cachexia exists. There 
is a pale anssmic appearance^ with occasionally a little dark pig- 
mentary deposit in the skin^ particularly about the eyelids, an 
air of general debility, and a pasty or waxy complexion. This 
would seem to be most commonly associated with the syphilitic 
forms. In other cases there is a characteristic appearance of the 
face with which I have become familiar, when the surface generally 
is pale and clear, but a very distinct conation exists over botn 
cheeks. This is not a congestion like a blush, but is seen by the 
naked eye to depend upon distention of narrow, small vessels, quite 
above the size of capillaries. These appearances, though interest- 
ing, do not seem to me important. But in many of the cases we 
have a distinct morbid condition of the blood, along with a slight 
increase of the colourless corpuscles. We observe that the red 
are soft and flabby, tending to tail, and form groups rather than 
rouleaux as do healthy corpuscles. This condition seems to depend 
upon affection of the spleen and lymphatic &;lands with the amyloid 
degeneration. In not a few instances the liver is found enlarged, 
sometimes to an immense extent, and whenever we find this con- 
dition, as well as those above indicated, we have a certain amount 
of evidence corroborative of the other more important symptoms. 

The Previous History is often of great value in assistmg us to 
arrive at a conclusion on the question of the nature of such cases. 
The fact has long been known that the amyloid degeneration is 
induced by long-continued wasting diseases, particularly syphilis, 
caries, and necrosis, and thus it is obvious that the fact of any of 
these having occurred in the previous history is in so far an evi- 
dence that the case of Bright's aisease is one of this particular form. 
At the same time, it is by no means a constant occurrence that these 
^maladies precede the degeneration, and they are therefore not to be 
looked for in every case. 

The Duration of the Disease is evidently, from some of the instances 
recorded, very protracted. One of my cases (A. M.) has been under 
observation for upwards of four years, and though it was during 
that period that his albuminuria first appeared, we have no positive 
proot how long the polyuria had previously existed. The case also 
of E. B. was under observation for more than three years and a 
half, and when he first attracted my attention he had for some time 
been affected. The woman E. H., whose body was examined in 
Jiuie, had been under observation for four years, and had 
throughout presented the same characteristic symptoins. In many 
cases, then, it would appear to be very chronic, and I have not yet 
seen a case from the very commencement of the renal symptoms to 
its fatal termination. The health of those who are suffering from 



18ei.] AMTtOlD FOkM OF BBIGHT's DI8EABE. Ill 

the maladjr is never good ; they are weakly, and have a great want 
of vital force, and are apparently very liable to other affections. 
They are subject to pains, aches, hemorrhage ; but on the whole do 
not suffer mach from their degeneration, unless when it happens to 
occur in the intestine, when the wasting diarrhoea becomes a dis- 
tressing symptom. 

I%e Modes of Terminaium ofAe Ca$ei. — A lar^ majority, indeed 
almost all, seemed to pass on to a fatal termination ; but from two 
cases, Nos. 15 and 17, 1 am inclined to think that it is not invariable. 
In both of these instances the albuminuria disappeared from the 
urine, and even the quantity of that fluid became diminished under 
the influence of tonics and good diet and regimen. In one of them 
this has gone on to what seems a complete recovery. In the other, 
relapse occurred so soon as she was deprived of the favourable 
surroundings in which she had been temporarily placed. 

When it terminates fatally it would seem to lead to death in a 
variety of ways, most commonly by a disease superadded to the 
degeneration, sometimes an inflammatovy affection of the kidneys, 
sometimes a disease of the bronchi, and sometimes from the ordinary 
concomitants^ such as phthisis pulmonalis. In no case have I seen a 
patient die simply of the degeneration or its direct consequences ; 
there seems to be always another disease superadded. 

TreaknenL — ^The cases which I have recorded render it perfectly 
evident that, under judicious treatment, the symptoms of this 
degeneration may be greatly ameliorated, and perhaps the degenera- 
tion itself cured. The rules which seem to me most important are, 
latj To attend to the nutrition of the patient, giving good nutritive 
food in the forms best suited to the individual tastes and powers of 
digestion ; 2^9 To give such tonic medicines as may improve the 
appetite ; 3dy To give such hasmatic medicines as control the ten- 
dency to anaemia, and among these pre-eminently the syrup of 
the iodide of iron ; 4t&, In all cases in which a syphilitic infection 
has been traced, and even in many others, to give the iodide of 
potassium in moderate and sustained doses. The effects of these 
medicines are often very striking^ and in particular the influence of 
iodide of potassium in diminishing the oulk of the liver is most 
remarkable. Ag^in and ^ain I have seen the size of the organ 
diminish under its use. In many cases all that we can do is of 
little or no avail, and the patient becomes worse and worse, and 
ultimately sinks. 

Let us now fflance at tlie amount of evidence we have collected. 
I have recorded in my two papers thirty-four cases, in all of which 
a certain series of symptoms was observed, which svmptoms I 
associate with the waxy or amyloid degeneration of tne kidney ; 
one of the forms of Bright's disease. In nineteen of these cases a 
post-mortem examination has been made, and in all of them the 
expected lesion has been found. In no case hitherto have I 
examined a body expecting the lesion and not found it. This 
evidence seems to me to prove that in many cases of the degenera- 



112 DR REId's cases of delirium tremens [AUG. 

tion the symptoms are such as I describe, and are so distinct as to 
enable us positivelj to distinguish it from other forms of renal 
affection. But I bj no means assert that I have absolutely esta- 
blished my views, and still less that I shall not likely require 
to modifjT them. 1 recommend the subject anew to the attention of 
the prorcssion, anxious to test my obseryations by the general 
experience, and only recommending a very careful sifting both of 
the history and symptoms before a diagnosis is attempted. 

ARTfCLE II. — Gtues of Delirium Tremens treated with Large Doses 
of the Tincture of Digitalis. By John Watt Reid, M.D., 
Surgeon, R.N. 

The following cases came under my care whilst I was in charge of 
the Royal ifaval Hospital at Halifax, Nova Scotia. As they 
appear to me to possess some points of interest to the practitioner, 
I now lay them oefore the Profession. 

Case I. — J. S., aged 41, boatswain's mate, a large-framed 
powerful man, was admitted on the 6th June 1862, with delirium 
tremens of 24 hours' standing, said not to be his first attack. 
Three half-drachm doses of tincture of opium had been given, and 
he had slept about half an hour. When admitted there was much 
tremor ; but he was by no means violent, and he did not wander 
very much ; the pulse was 92, soft, small, and irregular. Until the 
afternoon of the 9th he was treated with opiates and stimulants, the 
bowels having been kept open by injections, without any sleep 
being obtained. He had become extremely restless, and talked 
constantly. 

At 3 P.M. on the 9th, the pulse being then 120-132, rather small 
and hard, and the pupils much contracted with injected conjunc- 
tivae, half an ounce of tincture of digitalis was given. At 8 p.m., 
as he still had not slept, a similar dose was repeated ; and at 11 p.m. 
he got two drachms more. The pulse continued regular, and had 
fallen 20 beats. He was a good aeal quieter, and looked sleepy. 

10^. — After the last dose he lay quiet, only tumine now and 
then; and at 4 A.M. he fell asleep. He did not awake until a 
quarter to 6 P.M. (indeed I roused him up), when he spoke quite 
sensibly and calmly. However, at 7.30 p.m. he suddenly started 
up in bed in an excited mannef ; and then, as the pulse was 96, 
quite regular and good, another two-drachm dose was given. 

llih. — He slept from 10 p.m. until 5 a.m. During the day he 
got an aperient aose, and he took an egg, beef-tea, etc. In the 
evening, although he had slept at times during the day, and his 
manner and appearance were quite quiet and con^sed, two drachms 
were given as a sleeping draught. Subsequently he needed nothing 
but nourishing diet, with porter, vegetable bitters, a laxative, etc. 
In this case the pulse never intermitted, and did not fall below 
84-96, although so large a quantity of digitalis was given. I may 



16M.] TREATED WITH LAME 00«E8 OP DJOrTALIfl. 113 

here remarkj Aai eertamly lAe loH doKy amd, periajm^ oUo tke cm 
hefimrey wob ufmecestary. 

Case II. — J. B., aged 44, able aeaman, a spare but muscular nan, 
was admitted on the moming of the Idth June 18^2. He had \iefn 
placed apon the sick-list in his own ship on the l^th, ha%'in); 
previously been on shore drinking for five or six day*. The 
sjnnptoms at first were much tremor and sleeplessne^^ with vcimit* 
ing, for which opiates and stimulants had been given without Unrnt. 
On the 14th, be had become delirioos, with occasional violt-TK^ 
which was said to be increasing. When admitted he w«ii<J«*rfd 
much, and was restless and obstinate, bat not violent; the eyes 
were oleared and fiery; the tongoe was red and clean, but ni<»i5t ; 
the bowels were open ; the poise was 116, fall and forcible. It waA 
said that he had slept a very little on the evening of tlie 13th. 
Half an ounce A tincture of digitalis was given at 10 A.if . : and at 
1 P.M., as he was then in much the same stale, a mmilar do« was 
repeated. He fell asleep at 3 p.m.. and slept until 9.30 P.M. On 
awaking he vomited a good deal of bile, without any smell of 
digitalis. 

At 11 P.M., not having again fidlen asleep, and the raise being 
96-102, and quite refi;ular, two drachms were given ; oat almost 
immediately afterwaraB he vomited. In a few minutes he dozed 
off; and he slept the whole nig^t afterwards. Next moming he was 
quite rational, and said that he felt well, <mly weak ; the pulse was 
60, occasionally intertniuina. Nourishing diet, porter, vepretable 
bitters, etc, were afterwards given. In Mtf ooae, oZso, one dose loo 
much was given. 

Case IU. — ^H. M., set 38, caulker, a stout muscular man, was 
admitted on the moming of the 18th June 1862. There had been 
no time for treatment, as he was sent to the hospital immediately 
upon being taken on board his ship. He wandered much, but there 
was no great degree of tremor; the puLae was 96, full and strong ; 
the tongue was white and moist Half an ounce of tincture of 
digitalis was given at 10 A.M. ; and at 2 p.m., being then cjuieter, 
with a softer and still regular pulse, and although he complained of 
slight nausea^ a similar dose was repeated. 

At 6 P.M. ne had not slept; the pulse was 48, intermitting trery 
two or three beats with a thrill, but of good strength. He had 
vomited some tea (which had been given against orders), half an 
hour before. After taking a little arrow-root he fell asleep ; and he 
slept calmly until 7 a.m. next morning. 

At 9.30 A.M. (on the 19th), die pulse had not risen above 48, 
but it was quite regular and good. 

He continued well, and convalesced rapidly. 

Case IV. — ^T. A., aged 28, able seaman, a short muscular roan, 
was admitted on the moming of the 12th November 1 862. He bad 
had half a drachm of tincture of opium when taken to the sick-bay 
on board, at 8 A,M. that day, having returned to his ship from 

VOL. X. — NO. n. p 



114 DR reid's cases of delirium tremens [Aua. 

broken leave during the previous night. When admitted there was 
great tremor, with frequent rigid spasms ; he was very restless and 
alarmed, and would not reply to a question; the pulse was 112- 
120, and full. 

Half an ounce of tincture of digitalis was given at 10 a.m. In less 
than half an hour he was calm and answered reluctantlv and slowly, 
but rationally ; and soon afterwards he fell asleep. When he awoke 
in the evening he was quite composed and sensible, took some 
arrow-root, and slept again. The pulse was 96, regular, and good. 
Next day he got some calumba and bismuth, and he speedily was 
quite well. 

Case V. — A. A., aged 29, private marine, a well-made, strong 
man, was admitted on the 6th June 1863. He had had a grain of 
morphia the evening before when first seen on board his ship. 

On admission he trembled much, and had a wild^taring expres^ 
sion ; he was only partially sensible, and articulated with consider- 
able diflScultv, but lay muttering and mumbling ; the pulse was 96- 
108, full and soft ; the tongue was coated and moist. 

10 A.M. — Half an ounce of tincture of digitalis was given (as in 
the former cases, with the same quantity of water). 

1 P.M. — He was much calmer, and spoke more distinctly and 
rationally. The pulse was 96, smaller, qmte regular. A similar dose 
was repeated ; but at 2 p.m. he vomited matters smelling of digitalis. 

6 P.M. — He had taken and kept down some arrow-root, and had 
Iain almost quite quietly, but had not slept. The pulse was 72, 
oocasionaUy intermtUinff. 

11*30 P.M. — He had dozed a little. All tremor had left him. 
The pulse was 60-72, and intermitted as before. He complained 
of cardiac oppression and slight headache. 

7th June. — He slept nearly four hours in the middle^watch. The 
pulse was 48-56, intermitting, of fair strength. He was quite 
collected, and said that he felt much better ; he had no headache, 
but still complained of some degree of uneasiness in the region of 
the heart. A bitter infusion was ordered ; and strong beef-tea, with 
bread, was given. In the evening the pulse, which had been in- 
termitting less and less during the day, was 60, and almost quite 
regular. Two drachms of the tincture were given at 9 p.m. as a 
sleeping draught, but vomiting occurred about 11 P.M. However 
he slept the greater part of the night afterwards. Convalescence 
ensued steadily. In this case, as in Cases I. and II, one dose more 
than voaa required^ or vxis judicious^ toaa given. 

Case YI. — B. S., aged 34, private marine, a middle-sized, 
muscular man, was admitted on the 26th June 1863, without any 

Erevious treatment. He had broken his leave, and been drinking 
ard, and leading a very dissolute life for nearly a week. When 
admitted there was moderate tremor ; he wandered but little, and 
could be readily made to answer rationally ; he lav with a fixed, 
staring, penitent expression ; the pulse was 108, full and soft ; the 



1864.] TREATED WITH LABOE D0AE8 OF DIOITALT8. 115 

tongue was coated and dry. Half an ounce of tincture of digitalis 
was given at 10 a.m. 

3 P.M. — There was little or no change, only the pulse was 72, 
but quite regular. 

5 P.M. — He vomited a good deal of greenish matter, without any 
smell of digitalis. The pulse was 60| and still regular. He was 
inclined to sleep. Some arrow-root was given, and kept down. 

8 P.M. — ^He was dozing. The pulse was 48-52, intermiuing 
after twelve or fourteen beats. He had no cardiac uneasiness. 

21 ih June. — He slept several hours during the night The pulse 
was 68 to 72, intermitting as before. Afterwards nourishing diet 
and tonics were given. Convalescence was slow, owing to the weak 
state of his stomach, etc., caused by his previous dissipation. 

Remarks. — ^I have but a few remarks to add, for the cases, short 
as the^ are, speak sufiBciently plainly for themselves. No doubt 
the digitalis was pushed ftirther than was necessary or even advis- 
able in Cases I., II., and V. ; but in the first, at any rate, I had all 
the zeal of a convert who had previously entertained a groundless, 
perhaps an unreasonable, dread and disuke to the remedy. I must 
own that I commenced the new treatment with apprehension, but 
at the time I had little or no hope of the man's recovery j in fact, I 
regarded him as a dying man, so I considered myself justified in 
the adoption of what 1 then looked Upon as an extreme measure. 

I would particularly call attention to the large quantity that was 
borne in tne first case, without inducing vomiting, or causing 
intermittenoe of the pulse, — ^to the vomiting which occurred in Cases 
II. and v. ; (is vomiting an indication of the limit of tolerance?), — 
to the almost instantaneous effect of the single dose in Case IV^ — 
and to the contrast afforded by Case I. to Cases III., V., and Vl., 
in the impression on the circulation. 

It seems to me that this digitalis treatment is more smtable for 
hospital patients, either in naval and military or civil life, than for 

Erivate practice, unless when the physician can see the case every 
our, or oftener, and can have an intelligent and trusty nurse by 
the bedside, with assistance at hand if need be. All my patients, 
too, were men in the prime of life, who had been previously in 
robust health ; and such treatment is perhaps more adapted for 
patients in similar circumstances, than for habitual drunkards with 
Droken-down constitutions. 

The precautions that I took were, to ascertain that no heart- 
disease existed, and to prevent the patient leaving his bed for any 
Eurpose before he slept, and for at least twenty-four hours after he 
ad regained his nervous control. I always saw, also, that he got 
a small quantitpr of strong beef-tea (essence of beef), or of arrow- 
root, at proper mtervals before sleep. 

I have only further to add, that the drug had been in my charge 
two and a half years, and had been supplied from the Boyal Naval 
Hospital at Plymoutn (originally from Apothecaries* Hall, London). 



116 DR PARKER'8 case OF DEATH RESULTING [AUQ. 



Article III. — Case of DeaA resulting from the PrcusUce of Arsenic- 
Eating. By D. M^N. Parker, M,I)., Halifax, Nova Scotia. 

The repeated assertions of travellers, aided hj the occasional 
reports of medical men, to the effect, that the inhabitants of Styria 
and other parts of the Austrian empire have been accustomed for 
years to take increasing quantities of arsenic, with apparent benefit 
to their respiratory organs, general appearance^ and health, have 
doubtless had the effect of influencing many vam and thoughtless 
individuals to practically test the matter on their own persons. 
Fatal results have, I believe, been known to follow the habit in 
Styria ; but I am not aware that there is a published history of any 
such cases. Its novelty, its scientific bearings and interest, as well 
as the desire to prevent, if possible, the continuance of such a prac- 
tice, wherever it may have oeen adopted, induce me to give early 
publicity to the following case, which, unhappily, terminated fatally 
while under the professional cnarge of Dr Tupper and myself. 

A. C, photographic artist, unmarried, set. 30 ; a strong, muscu- 
lar, well-built man, two years since consulted me on account of an 
obstinate chronic sy{)hilitic throat. He was a private patient from 
November 1860 until May 1861, when, consiaering himself well, 
his visits were discontinuea. During this time he was taking one 
or other of the following preparations : — Iodide of potassium, iodide 
of mercury, bichloride of mercury. Fowler's or Donovan's arsenical 
solutions. He frequently complained of my prescriptions producing 
abdominal pain and diarrhoea, which symptoms were occasionally 
so urgent that I was obliged to discontinue the treatment, and resort 
to opiates and astringents. 

After May 1861, 1 occasionally met him in the street, apparently 
in the enjoyment of vigorous health, but saw nothing of him pro- 
fessionally until Thursday the 20th November 1862, when I 
received a pressing message to visit him at his lodgings, which I 
did at half-past ten o'cIock p.m. I found him in bed, suffering 
intense pain in the region of the stomach, which was not materially 
increased by pressure. The abdomen was much swollen and tym- 

Sanitic, vomiting was incessant, and thirst intense, with a constant 
esire for cold water, which, even in the smallest quantities, could 
not be retained. His pulse was 110, regular, but soft and weak; 
the skin was cool and moist; tongue moist, and coated with a 
thin white fur ; urine scanty ; respiration natural ; countenance 
anxious ; features contracted, and the face much thinner than when 
I had last seen him. His complexion was unnatural, and by gas- 
light, was of a dark greenfsh hue ; head free from pain, and intel- 
lect clear. 

He stated that for three or four weeks past he had suffered from 
what he considered dyspeptic symptoms, during which time he 
frequently complained of pain after meals, and could use little else 



1864.] FROM THE PRACTICE OF ARSENIC-EATING. 117 

than oatmeal porridge, or other lieht farinaceous food. On the 
Sunday previous (16th November), he walked a distance of twelve 
or fourteen miles, and in the evening complained of fatigue. Before 
retiring to rest he partook of a hearty tea, with cold meat. The 
following evening, contrary to his usual habit, he partook somewhat 
freely of brandy and water. That night (Monday^ he rested badly, 
and vomited frequently. ^ 

While engaged in examining the case, and endeavouring to ascer- 
tain the exciting cause of so much pain and suffering, he abruptly 
said, " Doctor, would the daily use of arsenic, for a long time, pro- 
duce this disease ? I have been in the habit of using it for years, 
and it has never before injured me ; but the idea has just struck me 
that it may be the cause of all the mischief; '* or words to this effect. 
I replied that the symptoms were analogous to those of arsenical 
poisoning, and then, as briefly as possible, elicited the following 
facts from him : — About four years ago, he met with an article in a 
newspaper, or magazine, relative to the practice of arsenic-eating in 
Styria. Struck with the reported results, he resolved to practically 
test the matter on his own person, and at once commenced the use 
of arsenious acid. At first he took it in minute doses, measuring 
the quantity with the eye, on the point of a penknife. Sometimes 
it was taken rolled up in thin paper, at other times it was merely 
placed on the back of the tongue and swallowed unprotected. 
Having always used it in this loose and careless way, it was im- 
possible for him to do more than give an approximate estimate of 
the quantity thus daily consumed. Pointing to a one-m'ain pill of 
onium made up with a small portion of soap, he said, if the quantity 
of arsenic he liad been daily using for the last five months were 
rolled up in the form of a pill, it would be as large as the one before 
him ; and his impression was that the last few doses were of even 
greater bulk — especially that ofJ?uesday the 18th, after which date 
no more was taken. He had hoped that by increasing the dose he 
would be relieved of painfid dyspeptic symptoms, which had been 
unusually troublesome for the two or three preceding weeks. He 
had on several occasions discontinued it for a few days, and once 
even for three or four weeks, but, fancying that he was not so well 
as when under its influence, resumed the practice. He was im- 
pressed with the belief that his spirits and general health were 
Detter under its use ; but stated most decidedly, that his complexion 
instead of being rendered more clear was on the contrary often 
made dingy, and anything but improved by it. It produced no 
appreciable effect on the respiratory organs, or. as he expressed it, 
'^ aid not improve the wind ; " and the muscular system, although 
remarkably well developed, did not appear to have gained any 
additional stren^h. The genital organs had, he thought, been 
stimulated by the arsenic. He had had a metallic taste in his 
mouth and throat for some time. 

On the previous evening, feeling very much worse than usual, he 



118 DR PARKER'S CASE OF DEATH RESULTING [AUQ. 

had consulted Dr Tupper, but had made no allusion to his suspicion 
of arsenic being the cause of his sufferings, and had indeed com- 
plained of symptoms mainly referable to his respiratory organs^ but 
nad made no mention of abdominal pain, or irritability of the 
stomach. Dr Tupper prescribed for the congestion of the lungs, 
under which he was evidently labouring. In Dr Tupper's absence 
from the city, I was sent for on the following day, found him in the 
state already described, and prescribed trisnitrate of bismuth and 
opium, in large and frequently repeated doses. Externally^ mustard 
poultices, with hot opiate and turpentine fomentations. For nauriah" 
mentj he was ordered barley-water, thin arrowroot, or beef-tea, 
whichever could be best retained on the stomach. 

2l8t — ^At my morning visit found him easier. The abdominal 
pain and vomiting had ceased ; otherwise, his condition was much 
the same as on the previous evening. He had slept but little. 
Continued the treatment general and local. I careiuUy examined 
the eyes, evelids, fauces, and anus, to see if I could detect by day 
any morbicl change in these parts, which was not perceptible by gas 
light. All were in their normal state, except the mucous membrane 
of the anus ; this was red and irritable, as far within the sphincter 
as could be discerned. Later in the day the pain and vomiting 
returned, when opiate injections, with prussic acid and tincture of 
opium by the mouth were substituted for the bismuth and opium. 

22d. — ^On visiting him at seven o'clock A.M., found him much 
altered for the worse. Had had no sleep. The burning pain of 
stomach and vomiting had continued all night. Abdomen more 
distended. Countenance more hippocratic and the complexion 
darker than on the previous day. Pulse hardly perceptiole; at 
times it could not oe felt Respiration 22. Tongue slightly 
iurred^ and white, but moist. Skin cold. Neither nourishment nor 
medicme could be retained in the stomach. Dr Tupper saw him at 
ten o'clock A. M. We agreed to return to the bismuth and solid 
opium, to place a large blister over the stomach, and to give him 
nutritive and stimulating injections. At midday his symptoms 
were . unaltered. The rectum would not retain the nourishment 
thus administered. Although pulseless, when exempt from pain, 
which was occasionally the case for a few minutes, he said he felt 
quite well, and strong enough to walk out in the street. Indeed, 
while thus circumstanced, not more than one hour before this visit, 
he rose froib bed, and unassisted, descended a flight of stairs to the 
duiing-TOom, where he remained for a few minutes, and then 
returned to his bedroom. At ten p.m., we could detect no pulsation 
in the radial, temporal, or subclavian arteries. The femorals gave 
a vexy feeble impulse. The heart's sounds, very indistinct and 
confused, could just be detected with the stethoscope, but its pulsa- 
tions could not be counted. Respiration 22. No dyspnoea. He 
conversed freely in a firm tone ot voice, giving us again a very 
intelligent and connected account of his arsenic-eating liabits from 



1864.] FBOM THE PRACTICE OF AB8BNIC-EATIN0. 119 

the beginning. While we were in the xoom, he ro«e from the bed 
anassiated, exhibiting in the act a very considerable amount of 
moflcalar strength, and went to the night-chair, but could void 
neither faeces nor urine. Tenesmus and strangury were exceedingly 
troublesome. The skin and extremities were cold. The {jupifs 
rather contracted. Only a few drops of urine had been voided 
during the past twentj-tour hours. The intense thirst from which 
he had heretofore simered had passed away; the irritability of 
stomach was also gone. Ue was directed to taJce milk and barley- 
water as often and in as large quantities as could be retained by 
the stomach. The opiate treatment by the mouth and rectum to be 
continued as circumstances and symptoms demanded. 

2Sd. — Half-past eight o'clock A. m. His attendants reported that 
he had passed a most distressing night from pain in the region of the 
stomach, and from painful but ineffectual attempts to relieve the 
rectum and bladder ; not even the smallest quantity of urine bad 
been voided. The opiate injections were not retained long enough 
to benefit him. He had until the last few hours been able to rise 
and visit the night-chair unaided, but now required a bed-pan. 
Had had no desire for nourishment, but had taken some beef-tea, 
and retained it. Since six o'clock a.m., he had been (ree from 
acute suffering, and had dozed a »x)d deal His mind had wandered 
much. The pupils were somewhat contracted. Tongue clean and 
moist Abdomen very tympanitic Bespiration 20, and not 
laboured. The extremities and skin were dry and veir cold. No 
pulsation perceptible in any of the arteries. A sliglit confused 
action of the heart could with difficulty be detected. On being 
roused, he said he '^ feels quite well, and will never be caught in 
such a scrape again." After my visit he continued to grow weaker, 
and to talk more incoherently, until half-past ten a.m., when be 
ceased to breathe. 

Post-mcriem Appearancea and Examination. — Sanguineous fluid 
commenced to flow from the mouth and nose in large quantities a 
few hours after death. When seen twenty-four hours after his 
decease, the whole body was enormously swollen and disfigured. 
The abdomen was distended to the utmost limits. All the volun- 
tary muscles were excessively rigid. Flexing the limbs was per- 
formed with difficul^, owinjz to this unusual amount of rigor mortis. 
There was great lividity of countenance, and the skin of the face 
had a glistening appearance^ owing to emphysematous distention 
and excessive venous congestion. Both emphysema and capillary 
congestion were general on the surface of tne body, and air could 
be freely detected by the touch wherever sought. The penis and 
scrotum were black and swollen firom decomposition and gaseous 
distention. On puncturing these parts, and making pressure, the 
confined air or gas escaped through the venous oozing, in rapidly 
succeeding bubbles. The sectio cadaveris was made by Drs Cowie 
and Gk>8sip, at eleven o'clock A.H., 24th November. 



120 DR Parker's case of death resulting [Aua. 

Head. — On removing the scalp, it and the pericranitim were 
found exceedingly congested, and the yessels contained air. The 
membranes and surface of the cerebrum and cerebellum were in the 
same condition. The membranes were firmly adherent to each 
other and to the cerebral surface at the point of junction of the two 
parietal with the occipital bone, extending continuously down 
through the fissure dividing the cebral lobes to the tentorium cere- 
belli. On removing the brain, it appeared to the touch unusually 
firm and resisting. Its substance, when cut into, was natural in 
appearance — not congested, — this condition bein^ confined to the 
surface and walls of the ventricles. The ventncles contained a 
small additional amount of fluid. The corpus callosum was unusu- 
ally soft. The sinuses and vessels of the pia mater contained a 
quantity of air, which escaped in bubbles wnen these were opened 
or divided. The blood of the brain, as of the whole body, was 
black and in a very fluid state. 

Thorax. — The deposit of adipose tissue over the thorax and 
abdomen was rather lar^e. The pericardium contained two ounces of 
fluid. The left ventricle was largely hypertrophied and firmly con- 
tracted. Its muscular fibre was much more d!ense and hard to the 
touch than is usual in cases of hypertrophy. The left auricle was 
also empty and contracted. The walls of the right side of the heart 
were attenuated ; the auricle full of very dark liquid blood ; the 
ventricle collapsed and empty. The lungs were congested through- 
out ; perfectly engorged posteriorly. The oesophagus was not altered 
in appearance or structure. 

Abdomen. — There were about two quarts of fluid in the peri- 
toneal cavity. 

The Stomach externally was not much changed; internally it 
was but slightly congested over its first or oesophageal half. The 
congestion increased as the duodenal end was approached. Its 
mucous membrane was softer than natural. Between the mucous 
and muscular coats air was freely distributed, and could be moved 
from place to place by pressure. Patches of extravasated blood 
were also numerous between these two coats. The small intestine 
was inflamed or congested throughout. The duodenum was almost 
black ; the colour became lighter, and the congestion less, as the 
ileo-coecal valve was approached. Many large marks of extrava- 
sated blood were observed beneath the difierent coats and on the 
mucous surface, the largest being beneath the peritoneal covering of 
the Ileum. The large mtestine was lighter in hue, yet considerably 
congested, with here and there small patches of extravasated blood 
in its walls. The rectum was inflamed firom its commencement, 
but most so in the neighbourhood of the sphincter. The liver was 
of the natural size, mottled, and of a very peculiar dark greenish- 
blue colour throughout its entire substance. It was engorged with 
black fluid blood. The gall-bladder was lull of black bile. The 
spleen was also loaded with blood, and was of the same colour as 



1864.] FBOM THE PSACHCB OF ABSEIflO-XATOIO. 121 

the liver. It wbb of the normal sice and oonaiateiiee. The kidoejs 
were of the nsnal bicOi but very much congested. The Madder waa 
empty and contracted. Its urethral orifice waa congested. Porttona 
of the abdominal viBoera and brain were retenred far chemical 
examination. These were sabmitted to Professor How of King's 
College, Windsor, and Drs Cowie and Clossip, who reported as 
follows: — 

Knio*B CoLLBGB, WomsoB, NJ., Dm. 88, 1808. 

Dear Su*, — ^I have made two very carefol tests for arsenic, bj 
Beinsch's method, in the portion of*^ spleen received from 70a on 
the 19th inst I employed aboat two-thirds of the whole material, 
or rather more perhaps, and in both experiments I obtained an 
excessively faint sabumate^ of a white colour, bat I could not 
obtain, by careful heating m an oil-bath at a proper tempomtnre, 
in either case, the characteristic crystals of atsenious acid; so 
that I must conclude that I have &iled to obtain any evidence of 
the presence of arsenic As yon probably are aware, the delicacy 
and accurac]^^ of this test are such that, according to Tavlor (on 
Poisons), if it fails, there is hardly any reliance to be placed oo 
Marshes alone. 

Trusting that I have met your wishes, I am, dear Sir, yours 
truly, HaNBT How. 

C. Tapper, M.D., Halifia. 

Halifax, Deeember 1B68. 

Dear Sir, — We have made two examinations of parts of the viscera 
from the man supposed to have died from arsenic In the first 
(using the liver omy) slight indications of arsenic were obtained, 
by Marshes test, and by ammonio-sulphate of copper. In the test 
in which we used the stomach, duodenum, and ulcerated patches 
from the jejunum and ileum, not the slightest trace of arsenic could 
be discovered by either Marsh's or Beinsch's tests. — ^We remain 
yours truly, A. J. CowiB, M.D. 

Cha& J. O068IP, M.D. 

Dr Parker, Argyle Street, Hslifia. 

These chemical investigations demonstrate convincinglv the 
rapidity with which arsenic is eliminated from the system wnen it 
is taken in small quantities continuously. I had sujyposed that its 
chief receptacle — ^tne liver — ^would have detained it, if not in bulk, 
certainly in appreciable quantities; but when tested, only very 
slight traces ot the poison could be obtained from that organ. 

Bemarks. — ^It seems singular that a man of intelligence, whose 
daily occupation made him familiar with powerful chemical agents, 
should have partaken of arsenic for ^ears, and during all or nearly 
all that time, suffered from its use without suspecting the cause. I 
have learnt since his decease, from his most intimate friends and 
those with whom he lived, that although looking well, and to all 
appearance strong and robust, he had been, to use the words of one 

VOL, X.— -NO. II. Q 



122 DR parkeb's case of death resulting [AUG. 

of my infonnants, ^^ a complaining man for the last three or four 
years." Indeed^ so frequently did he refer to his pains and dyspeptic 
symptoms^ that those to whom he most frequently talked on the 
subject were in the habit of thinking and speaKing of his complaints 
as ima^nary. I have no doubt myself that the abdominal pains 
from which he suffered while under my care in 1860-61, on account 
of an affection of the throat, were produced entirely by the poison 
he was daily using. The quantity of arsenious acid taken into the 
system cannot be definitely stated. Guided by the statements of 
the dying man. I have taken eyery care to ascertain it as nearly as 
possible, andj m>m the data giyen, conclude that for the last fiye 
months of his life his daily dose was not less than two and not 
more than three grains. In this connexion I must state that while 
the few last doses, and especially that of Tuesday the 18th 
Noyember, were larger, he did not by any means lead me to infer 
that the increase was yery material. 

One thing is certainly taught by the circumstances and symptoms 
narrated in connexion with this case, yiz., that habit or continuous 
use does not be^t a tolerance of the agent in the animal economy. 
This is in accordance with the opinion of Professor Christison, that 
while the system may become habituated to the use of some of the 
organic poisons, habit does not diminish, but probably rather in- 
creases the actiyity of the inorganic poisons which enter the blood. 

It may be asked why antidotes were not used immediately on 
m^ ascertaining the cause of the patient's illness. I reply that the 
poison haying been taken in small quantities, and a period of sixty 
nours or thereabouts haying elaps^, after ^e last dose, before i 
saw him, during the greater part of which time he had been yomit- 
ing and purging freely, I concluded, and I think correctly, that 
the arsenic had either been absorbed or ejected from the alimentary 
canal, and that it was my duty rather to attack the effects than an 
absent cause. 

The cause of death in this, as in most cases of arsenical poisoning, 
is to be referred mainly and primarily to the state of the intestinal 
canal, especially of its upper portion. 

In making a few remarxs regarding the symptoms in this case, I 
must premise that I had neyer before had under my care a case of 
arsenical poisoning, and that, therefore, I had not the adyantaee of 
being able from my own experience to compare this with others. 
I may, howeyer, briefly allude to the points in which this case 
resembled the recorded obseryations of medical men, and those in 
which it appeared to present certain peculiarities. The symptoms 
of poisoning by arsenic usually obseryed, and which were present 
in the case now detailed, were the following :— Contracted features, 
and anxious countenance; dark and unnatural complexion; ab- 
dominal pain; tympanitis; metallic taste in the mouth; burning 
pain of tne stomach ; intense thirst ; tenesmus ; dyspnoea (present 
on the 19th, when seen by Dr Tupper, absent from the date of my 



1864.] FBOM THE PRACTICE OF AB8ENIC*£ATING. 123 

first visit) ; feeble cardiac and srterial action : coldness of surface ; 
strangoiy ; diminished quantitj, and eventaal suppression of urine. 
The absence of dyspnoea during the last few days of life struck me 
as being an anomalous feature of the case. The lungs were 
evidently gorged with blood, and there was great abdominal pain : 
notwithstanding which, the respirations did not at any time exceed 
twenty-two in the minute. Again, the state of the circulation 
surprised me: here was a man pulseless for twenty-four hours 
before death, with intellect clear and undisturbed, and feeling 
during the absence of pain mite weU, and with phvsical strength 
sufficient, while in this condition, to rise unassistea from his bed, 
to descend and ascend stairs, and to walk with a firm step all over 
the house. 

The following symptoms, more or less frequently observed in 
other cases, were absent in th%8y viz., a congested or cedematous 
condition of the eyelids and oonjunctivs ; cutaneous eruption ; a 
diseased state of the hair and nails ; yellow vomiting ; salivation ; 
discoloured and swelled penis ; cramps and tetanic contractions of 
the limbs ; head symptoms ; palsy. 

I may here refer to a result of arsenic-eating, not recorded, so far 
as I am aware, by previous observers. I refer to its action on the 
genital organs. In reply to a question proposed to him, he said 
that it was his impression that these organs were stimulated by its 
use. I would hesitate to record the circumstance if it were founded 
merelv on this statement ; but I have since learned that for a long 
time he had been notorious for his amorous propensities. 

I have before stated that A. C. gave a negative reply to the 
question as to whether his complexion had been improvea by his 
arsenic-eating habits. It is but ri^ht to add, that manv of his 
friends are equallv positive in asserting the contrary. They sav 
that his improved pinkish complexion, as if paint had been used, 
had frequently of late attracted attention, and been the subject of 
remark among them. 

The post-mortem appearances found in this case were such as 
have usually been met after poisoning by arsenic. The onlv points 
worthv of remark appear to be the unusual rapidity with which 
putrefrtction set in at a cold season of the year, and the very emphy- 
sematous condition of the cellular tissue. 



Abticlb IV.— 7^ FhysiologuxU Actions of Dqfakschy^ an Arrow 
Poison^ used in Borneo. By Peter M. Bbaidwood, M.D. 

ExPEBiM ENTAL researches as to the action of poisons on the animal 
organism present to the physiologist by no means an uninteresting 

* While working in his laboratory in Berlin. Professor Du Bois-Reymond 
kindly gave me thu poison, dajak»dk^ which he nad received from a doctor who 



124 DR BRAIDWOOD ON THE [AUO. 

field of inquiry, inasmuch as they either provide him with the only 
means of ascertaining certain physiological facts, or enable him to 
confirm results reached at by less refined methods of investigation. 
A good example of the latter is the working of the poison which 
forms the subject of the following paper. 

Characters of the Extract. — ^The aried extract has a dark iron- 
gray colour ; is firarile. It is dissolved by water, but not so readily 
as IS woorara; and, when finely pulverized, it is to a slight extent 
soluble in both alcohol and ether. It is not more soluble in hot 
than in cold water. Water dissolves it more readily in the presence 
of acte&, whereas alkalies do not increase its solubility in water. It 
IS insoluble in chloroform. The foregoing solutions give an alkaline 
reaction with test paper. The watery solution used for experiment 
had a bitter taste, was of a brown colour, and its odour resembled 
organic matter decaying in a moist place.^ 

Otneral Symptoms produced by me Poison, — ^The first noticeable 
evidence of the working of this poison, when administered subcu- 
taneously, is restlessness, and signs of irritation. These reflex 
movements are not those resulting from excessive pain, but resemble 
such as are produced by a mild local irritant. This is followed by a 
state of languor — ^the animal lying perfectly still, and the respiration 
being slow, but not laboured. Its posture, however, does not allow 
of the supposition of want of motor power, but only of indisposition 
to move. This condition is interrupted by several fits of convulsions, 
which increase in intensity firom time to time. By degrees, para- 
Ivsis, Bt first of sensation, and then of motion, sets in. The onset of 
the paralysis is in some instances not very marked, and in no case 
did the general paralysis seem to be an effect of the action of the 
poison. This paralytic stage shortly precedes death, and sets in 
mnn half an hour to an hour after the cessation of the heart's con- 
tractions. Lastly, the respiration is noticed to become heaving and 
irregular ; sometimes the respiratory movements are spasmodic, gasp- 
ing, and occurring at long intervals. In the case oi warm-blooded 
animals, vomiting and the passage of fceces and urine are noticeable 
svmptoms, which present themselves soon after the exhibition of 
the poison, and continue to a greater or less extent till general 
paralysis takes place. 

Specific Action of Dajaksch on the Pupil and on the Heart, — On 
the application of a couple of drops of a diluted watery solution of 

had been in Borneo. It waB in the form of an extract, wound round a small 
piece of stick, and dried thereon. It was wrapped up then in paper, and sealed 
m a piece of bamboo about three inches long, which bore tne inscription, 
<* Dajaksch : Pfeil-eift von Borneo." 

> From this simile it is not to be thonsht that the extract used was ahready 
too old and had begun to decompose. All those who smelt the watery solution 
considered its odour to be quite cnaracteristic ; and though thie comparison is not 
perfectly accurate, it is as nearly so as possible. The odour, moreover, does 
not increase as the solution is kept longer, and is not very strong, though 
marked. 



1864.] PHYSIOLOGICAL ACTIONS OF PAJAKSCH. 125 

Dajaksch mixed with glycerine, between the eyelids, in the case of 
the lower animals the iris was found to contract But this effect 
was not nearly so marked as that noticeable on the use of the 
Calabar bean; and therefore it is only incidentally noticed here. 
In those cases in which death resulted from the use of the poison, 
the contraction of the pupil was first obserrable at the commence- 
ment of the convulsive stage, and lasted till general paralysis set in. 
when the pupil began again to dilate. Though this poison producea 
contraction of the pupil in the lower animais, it is not to be con- 
cluded that it has the same effect on the pupil of man ; for it has 
been repeatedly found that poisons which, to a marked extent, 
contract the pupil in the lower animals, do not act on the human 
subject. 

The Complete CeeeaHon of Cardiac Actiim is, however, the char- 
acteristic enect of dajaksch on the animal organism. In the course 
of a short time (varying according to the amount and strength of 
the solution used), after the subcutaneous administration of the 
poison, the hearths pulsations are found to become feeble. Shortly 
thereafter the heart contracts irregularly and peristaUically. The 
irregular pulsations consist in the auricles contracting twice as often 
as the ventricles,— once with the ventricles, and once during the inter- 
mediate pause.^ By degrees the ventricles cease to contract, and ex- 
hibit only a slight heaving movement of their walls, by the blood 
passingthrough them ; and at last they become eimuUaneaualy motion* 
less. Some time thereafter (about half an hour when the dose is 
small), the auricles are observed to pulsate more and more slowly and 
feebly, and at last they also become motionless. General motion and 
sensation are as yet unimpaired; so that, if the experiment be 
made on a frog, and it be at this stage released from its fastenings, 
it jumps about briskly with an immovable he-art. No portion of 
the cardiac organ is re-excitable, either by mechanical or electrical 
means after it has once become paralyzed. The heart ceases to 
contract in systole. The ventricles are observed to be bloodless and 
pale, whereas both the auricles contain blood — ^the left auricle and 
the veins leading to it being distended with dark-coloured blood. 

PoH-mortem Apf^rances. — These are by no means characteristic. 
Besides the condition of tha heart which has just been mentioned, 
the other or^ns of the thorax and abdomen are sometimes partially 
hvpersBmic, but present to the naked eje no other appreciable 
alteration. The muscles of the extremities contracted readily in 
the case of frogs when excited directly or through their nerves by 
a current of electricity ; whereas the experiments made on warm- 
blooded animals e;ave this curious result, that a strong electrical 
stream produced aliaht contractions' of the voluntary muscles when 
they were excited directly, but failed to produce contractions when 

^ These irregular and peristaltic contractions of the ventricles are best 
observed in the frog. In tnese animals the ventricle «an be distinctly seen to 
contract peristaltically (like the intestines) from the apex to the base. 



126 DR BRAIDWOOD ON THE [AUG. 

passed through their nerves. In both classes of animals the muscles 
retracted on being incised. Electricity^ moreover^ had no power 
in renewing the contractions of the heart or of the intestines after 
death. 

This diyersity on the part of the voluntary muscles of frogs may 
perhaps be accounted for by the well-known extraordinary con- 
tractile vivacity of the muscles of these animals^ as compared with 
those of others. 

The question now suggests itself, How does this poison — dajaksch 
— ^produce the paralysis of the heart ? Exclusive of a direct para- 
lysis of the muscular fibres fwhich is not likely to be the case, 
seeing the other muscles of tne body remain so long unaffected), 
this phenomenon may be produced through any one of the three 
nervous sources which supply the cardiac nerves, viz., through the 
vagus, through the sympathetic system of nerves, or through the 
spinal cord. Experimental research has long ago demonstrated 
tnat the cardiac branches of the varas have the function of arrest- 
ing the heart's contractions, while those from the sympathetic are 
the truly motor nerves, and those from the spinal cord the probable 
sensory cardiac nerves. The proof necessary, therefore, to deter- 
mine this point requires to be ooth negative and positive. 

Commencing, then, with the former, three sets of experiments 
were made to exclude the action of this poison through the vagus: 
Firstly y The voluntary muscles of a frog having been completely 
paralyzed by means of woorara, which did not however m the 
slightest degree affect the contractions of the heart; a dose of 
dajaksch was next administered to it subcutaneously, and the result 
was as follows: — ^The latter poison exhibited its action on the 
heart in the same time and in the same way as it had done in frogs 
not previously poisoned with woorara. Secondly^ The medulla 
oblongata of other frogs was broken up with a needle, so as to 
destroy the origin of the vagus, and this in itself produced a 
momentary cessation of the cardiac pulsations ; but after these were 
renewed, a dose of dajaksch was given, with the result that it acted 
on the heart exactly as it had done in the case of normal healthy 
frogn9. Lastly y The vagus was divided in its course, and on the 
application of the poison the effect on the heart was exactly the 
same as in both the previous instances, provinjg that dajaksch does 
not paralyze the heart through the vagus. What further confirms 
this conclusion is the fact that irritation of the vagus produces only 
temporary paralysis of the heart ; whereas, after the use of dajaksch, 
the heart cannot by any means, mechanical or electrical, be re- 
excited to contraction. 

Besides the circumstance that, as the results of experimental 
observation, the cardiac branches supplied by the spinal cord seem 
to be for the most part sensory nerves, this source is nirther excluded 
by the following consideration, — Tnat the paralysis of sensation 
and motion do not set in, in the case of poisoning with dajaksch, 



1864.] PHT8I0L0GICAL ACnONfi OP DAJAUCH. 127 

till long after the heart has been completely paralysed* Moreover^ 
post-mortem research does not lead ns to suspect paralysis through 
the spinal cord* Therefore, nothing now remains to us except to 
conclude that the paralysis of the heart results firom the action of 
this poison on the sympathetic cardiac ganglia. 

Positive proof of the foregoine assumption, and an explanation 
of the manner in which the paralysis attacks the several chambus 
of the hearty is afforded us by the following fact : — If the heart be 
removed from the body immoliately after it is apparently paralysed| 
but while the animal possesses general sensation and motion unim* 
paired, and Stannius experiment be made on it, we have Ithis 
result, — ^that on exciting the ganglion of the smus venosus with a 
Btrang stream of electricity, the auricles are observed to contract 
twice slightly, but the ventricle not in the slightest degree; 
whereas, if the auricles be separated from the ventricle, neither con- 
tract on being electrically imtated. 

Condudona. — ^We may conclude, then, — 

1st, That this arrow-poison, dajaksch, produces death by para- 
lyzing the heart ; which is proved further by the frict, that, after 
ligature of the heart, death results in the same way and in about 
the same time as after poisoning with dajaksch. 

2^, That the cessation of the cardiac contractions is brought 
about through a paralysis of the cardiac ^nglia of the sympathetic, 
exactly as the same is seen on performing Stannius' experiment 
In other words, that with this poison we have a much finer means 
of performing Stannius' experiment than the knife and forceps 
afford us. 

3^. Hence, that the ventricle first ceases to contract, because the 
ganglia situated between it and the auricles, and which for the 
most part sonply the ventricular sympathetic nerves, are first 
paralyzed. Then that the auricles become motionless after the 
ganglia supplying them (the ganglion of the sinus venosus in 
frogs) are paralyzed. 

Aihy That the other general phenomena produced by this poison, 
as paralysis of general sensation and motion, etc., may be oonsiderea 
as the natural results of the paralysis of the heart. 

Experimenta made with Daj AKSCH, illuHratwg the prevUnu Remarka. 
A. Itbutra&ng the ConstituiUnud Effects of the Poiaon. 

1. IN THE CASE OF GOLD-BLOODED ANIMALS. 

Experiment 1. — ^AdminiBtered to a frog (which luid been kept at lesat 
twenty-four hoars in the laboratory), sabcutaneonsly on the bftck, a dote of a 
watery solution of dajaksch. This dose was equal to about twice the common 
dose of a similar watery solution of woorara. 

Immediately after the exhibition of the poison, the animal moved restlessly 
about. In twenty minutes thereafter, it lay quiet. In seventy-two minutes the 
ttof was apparently partially paralysed, and dragged its hind-legs when strongly 
tmtated. During this time it moved restlessly at intervals, and the paralytic 



128 DR BRAIDWOOD ON THE [AUQ. 

condition was preceded by convulsions. In eighty -five minutes after the ex- 
hibition of the poison, the animal submitted itself to be laid in any position, 
and did not evince the slightest signs of the presence of motion or of sensation. 
The pupils were noticed to be contracted to half their normal size. Ten 
minutes after this no respiratory movements could be distinguished ; the eye- 
lids were open, and the animal appeared to be dead. 

AtUqm — immediate. — ^The heart was found to be perfectly still, and not at 
all excitable on the use of any mechanical irritation. The left auricle was 
noticed to be greatly distended with dark-coloured blood. The organs 
generally, especially the stomach, lungs, liver, and kidneys, were somewhat 
congested, llie intestinal canal did not appear hypenemic. The muscles of 
the limbs contracted when irritated by an electricfu stream both directly and 
through the main nerve of the limb. 

n. IN THE CASE OF WABM-BLOODED ANIMALB. 

Experiment 2. — ^Injected subcutaneonsly into the thigh of a well-grown 
adult rabbit rather more than a cubic centimetre of a watery solution of 
daiaksch. This dose contained a half-grain of the dried extract. Three 
minutes after the exhibition of the poison, on being freed, the animal moved 
about restlessly. Diarrhoea and urination took place.' The vessels of the ear 
were observed to contain less blood than formerly. In seven minutes there- 
after the animal lay quite quiet. The vessels of the ear were again refilled. 
On being looked at five minutes later, the animal continued to lie in the same 
motionless state, and the vessels of the cartilage of the ear again appeared to 
be contracted. Twenty minutes after the exhibition of the poison, the rabbit 
appeared quite dead. Death was preceded by slight convulsive momements 
of the extremities. 

Autopsy — ten minutes after death, — ^The heart was motionless. On being 
opened the ventricles were found to contain a very little blood. The ri^ht 
auricle was devoid of blood ; but the left auricle, as well as the veins leading 
into it, were noticed to be distended with dark -coloured blood. The lungs, 
liver, kidneys, and whole intestinal canal did not present to the naked eye any 
abnormal appearance whatever. When irritated directly by an electrical stream, 
the muscles of the extremities contracted very slightly ; but the muscles of the 
thorax and abdomen were not at all excitable by electricity. A few minutes 
later the muscles of the extremities also gave no contractions with an induced 
stream of electricity. None of the voluntary muscles contracted when incised, 
or when the chief nerve of the limb was divided, or when excited by an 
electrical stream passed through the chief nerve of the limb. The ventricles 
were not excitable to contraction by an electrical current ; but the auricles 
contracted readily by this means. When tested again, thirty-five minutes after 
the death of the animid, the auricles were found to be less excitable by elec- 
tricity. Fifteen minutes thereafter slight contractions of the auricles were 
produced by electricity. Three minutes later the right auricle could not be 
excited any more to contract, and the electrical stream caused contractions 
only at the most distant part of the left auricle. Twelve minutes after this, 
and sixty-five minutes after death, no part of the left^ auricle was any longer 
excitable by electricity. 

Experiment 3. — Administered to a young cat subcutaneonsly in the left thifih 
a dose of the watery solution, equal to a quarter-grain of the dried extract. In 
fifteen minutes after the exhibition of the poison, fseces were passed. This was 
followed by vomiting, and the animal shrieked in sreat distress. Between the 
paroxysms of sickness, the cat lay crouching in a dark comer of the room quite 
■till ; but, on being strongly irritated, it moved, showing voluntary motion to be 
unafiected. The paroxysms of vomiting recurred at short intervals, and were 

{{receded by loud shrieking. Fifteen minutes later, the cat appeared quite 
istless, and allowed itself, without offering any resistance whatever, to be kud 
in any position. Sensation seemed to be absent. The heart, on being examined, 
from time to time, through the thoracic wall, was noticed to be pulsating more 



1864.] PHYSIOLOGICAL ACTION OF DAJAKSCH. 129 

and more rapidly and irregularly. Thirty-two minatea after tlia admimatrB- 
tion of the poiaon, strong conTuUions of tne whole body occurred. J oat before 
theae convulsive paroiysma, the heart could be no longer diatingniahed by 
feeline through the thoracic walL Immediately after theae fita paaaed off tfai 
animiQ darted into the centre of the room acreaming ; but finain^ a want of 
power in ita hinder limbs it could not run further, and ao dragged itcelf alone 
for a few inches and fell on ita side. A few seconds thereafter it atmgglea 
strongly to recover its former position ; but, being unable to aupport itaelTany 
longer, it apread ont its limba and lay on its belly with its head turned to tlw 
left side. In a few seconds it gave a loud shriek and died. The pupila were 
noticed to be dilated ; the lower jaw was dropped. 

Auiapttf^^mmeeUaie. — ^The heart waa motionless and not excitable by me- 
chanical irritation. Its cavities presented the aame appearance aa m the 
previous experiment. The veins or the thorax and abdomen were found dia- 
tended with dark-coloured blood. The stomach contained some frothy mocua, 
and waa alightly congested towards its pyloric end. The other organs^ though 
examined, presented no abnormal hypersmic condition. The peristaltic move- 
ments of the intestines were absent. The muaclea of the extremities contracted 
when incised, but were not affected by mechanical irritation of their nerves. 

Experiment 4. — Gave an adult sparrow a dose of the solution, equalling 
about one-tenth ^in of the dried extract. Three minutes after the adminla- 
tration of the poison by the mouth, the bird having been flying about the roof 
of the room, suddenly fell down dead. 

Autopsy— -immediaU.—The heart was found passive, and its chamber! aeverally 
in the same condition aa in the previous expenmenta. The heart's contrmctlona 
could not be in the slightest degree excltea by mechanical means. The pupila 
were observed to be dilated. 

' Experiment 5.— Gave a large adult grey cat subcntaneonsly, in the left thigh, 
a dose of a watery solution containing rather more than one -tenth grain of tlie 
dried extract. Aoofft ten minutes after the exhibition of the poison the animal 
began whining, and was restless. This was continued at intervals. An hour 
after the poison had been given, occaaional vomiting and diarrhoea set in. 
Motion and sensation were unimpaired. An hour thereafter, the heart's pulsa- 
tions were felt through the thoracic wall to be very rapid and irregular. Sen- 
sation seemed to be slightly affected. Pupils were of normal sixe. Twenty 
minntes later, urine and fteces were observed to be paaaed very often. The 
fteces were fluid, yellowish white, and of a strong odour. Voluntary motion 
was unimpaired. The cat lay crouching and listless in a dark comer, and, 
when moved from its place, purred angrily and strove to eet back to ita comer. 
When Again observed, about an hour later, motion and hearing were found to 
be unaffected ; but vomiting still recurred at intervals. Half an hour there- 
after it continued to lie quietly in the dark comer when undisturbed ; but when 
approached it purred angrily, though it would not stir from its place. Vomit- 
ing, diarrhoea, and urination had now quite ceased. When the heart was 
examined through the thoracic wall it seemed to be pulsating irregularly, but 
not BO rapidly as formerly. On being looked at next morning, about twelve 
hours after the administration of the poison, the cat was founa languid, but in 
other respects it appeared to be in normal health. At first it would not drink 
any milk, but in a few hours it began to take ita food as formerly, and seemed 
to have quite recovered the effects of the poison. It seemed to have lain in the 
same comer all night, and in the same crouching posture. 

B. xUustmting the Special Action of the Poieon. 

I. IN PRODUCING CONTRACTION OF THE PUPIL IN THE LOWER ANIMALS. 

Experiment 1. — Poured a drop of a weak solution into the right eye of a 
rabbit. The ri^ht pupil seemed to begin to contract in about two minutes 
after the administration of the poison. About an hour later the right pupil 

VOL. X.— NO. II. R 



130 DR BRAIDWOOD ON THE [AUO. 

was observed to be half as large as the left one, and after another half-hoor it 
became two- thirds smaller than the left one. 

Experiment 2. — A few drops of a weak watery solution were applied with a 
brush to the right eyeball of a dog which had very active irides. When looked 
at about an hour after the application of the poison the right pupil was found 
to be contracted to half its normal size, and tq be more sluggish than the left 
one. Besides causing local uneasiness the poison seemed^to have no other 
effect. The pupil contracted to about one-third of its normal dimensions ; but 
after about three hours the poison appeared no longer to act on the pupil. 

U. IN PARALTZIMa THE HEART. 

(a) In ihe case of Frogs. 

ExPERiiiENT 1. — Exposed the heart in a frog, and found its pulsations to be 
46 per minute, regular, and of normal strength ; in five minutes thereafter gave 
it Bubcutaneously, in the thigh, a huge dose of a strong solution of dajaksch. 
Immediately after the injection of the poison the heart's pulsations were 46 per 
minute. In ten minutes after its exhibition the heart's pulsations were found 
to be 8 per minute, and feeble, but regular. The fro^ made strong muscular 
movements when irritated, but these did not in the shghtest degree affect the 
heart's pulsations. In eight minutes later the ventricle ceased pulsating, and 
the auricles contracted feebly and at irregular intervds. Four minutes there- 
after the auricles ceased to contract, but voluntary motion was found to be 
perfect. The paralysis of the heart was followed m seven minutes by inter- 
mittent convulsive movements of the extremities. During this convulsive 
period, respiration was slow and laboured. Before the ventricles ceased con- 
tracting, it pulsated more and more feebly, slowly, and not synchronously with 
the auricles. Voluntary motion continued unaffected for nearly three-quarters 
of an hour after the heart became motionless, but during this tune several con- 
vulsive fits occurred. An hour and seven minutes after the cessation of cardiac 
action the animal Uy dead, with its lower limbs stretched out behind. When 
an induced electrical current was passed into the muscles of the extremities 
directly and through the main nerve of the Umb, it caused contractions an 
hour and a quarter after death. 

Experiment 2. — On exposing the heart of a frog, its contractions were 
found to be 48 per minute, and regular. The poison was exhibited just as in 
the last experiment. Three minutes after the administration of the poison, 
reflex movements were noticed, but the heart's pulsations were found to be the 
same. In thirteen minutes after the commencement of the experiment the 
ventricle was quite still, and not re-excitable by mechanical or electrical means. 
Before becoming motionless, the ventricle pulsated more and more slowly and 
feebly, and then contracted in a peristaltic manner firom its apex to its base. 
The auricles pulsated 14 times per minute, but at regular intervals. Five 
minutes later the auricular pulsations were found to be 4 per minute, and, of 
these, 3 occurred during the first quarter of a minute. Two minutes thereafter 
the auricles pulsated 6 times per minute, but irregularly as before. Respira- 
tory movements were feebler. Three minutes later the auricles were observed 
to contract 5 times per minute, t.«., 4. times in the first twenty seconds, and 
then followed a strong contraction at fifty seconds. Sensation and motion 
were found unimpaired. When noticed, ten minutes later, the auricular con- 
tractions were 7 during twenty seconds, and then none for one and a half 
minute, when a strong contraction occurred. In ^^ minutes thereafter slieht 
convulsions of the lower extremities seemed to be present. The auricular 
pulsations were 2 per minute, and at regular intervals. For twenty-one 
minutes after this the auricles continued pmsating, but more and more feebly, 
very irre^larly, and at long intervals. Then they suddenly ceased contracting. 
The respiratory movements were observed to be laboured, and to occur at long 
intervals. Sensation and voluntary motion seemed to be unimpaired. Half 
an hour after the paralysis of the auricles the animal was found to have lost 
sensation and motion, and appeared dead. 



1864.] PHYSIOLOGICAL ACTION OF DAJAK8CH. 131 

ExPEKiHENT 8. — On taking a frog and exposing its heart, whose eontrac- 
tions were 40 per minote, regular, and of normal strength, I administered to it 
a good large dose of dijaksch, snbcataneously as formerly. In nine minutes 
thereafter the cardiac pulsations were found to be 18 per minute, and regular, 
but feebler than before. In eleven minutes after the administration of the 
poison the ventricle was observed to contract non-s^chronousiy and peristaltic- 
all^ from apex to base. Six minutes later the auricles were found to contract 
twice as often as the ventricle,— once with the ventricle, and once in the interme- 
diate interval. But both sets of contractions occurred at regular intervals. 
Three minutes after this the ventricle ceased to pulsate, and was not re-excit- 
able. In eight minutes after the paralysis of the ventricle, the auricles exhi- 
bited very feeble heaving movements, not to be called contractions. General 
sensation and motion were at this time found to be unimpaired. Three minutes 
later, and half an hour after the exhibition of the poison, the auricles were 
found passive. Sensation at this time was somewhat impaired, but not motion, 
for the animal jumped about briskly when freed. In rather more than half an 
hour after the cessation of the cardiac contractions, general sensation and 
motion were found to be absent ; the frog submitted to be laid in an^ position. 
At this time the heart was cut out of the body, and Stannius' experiment per- 
formed on it, with the following results : — On irritating the ganglion of the smus 
venosus with an electrical stream, the auricles contracted each time after being 
twice irritated, but not oftener ; whereas the ventricle remained motionless on 
being irritated. On separating the auricles from the ventricle, neither contracted 
on being irritated. Tnese two slight contractions of the auricles were therefore 
the last traces of their contractility. Five minutes after the heart had been 
removed, the ftof gasped and died, llie pupils were observed to be of normal 
siie. When an mduced current of electricity was passed through the muscles 
of the extremities directly, and through the sciatic nerves, it elicited normal 
contractions of the muscles. 

Experiment 4. — ^To a frog, whose heart had been exposed, and its pulsations 
found to be normal, was given subcutaneously a dose of the watery solution, 
containing about a grain of the dried extract. In five minutes after the exhi- 
bition of the poison the animal was very restless, and exhibited strong reflex 
movements. Ten minutes thereafter tne cardiac pulsations were irregular, 
much slower than at first, and very feeble ; and two minutes later the ventricle 
was observed to be motionless. The auricles ceased to pulsate half an hour 
after the ventricle had stopped. A strong electrical stream elicited no con- 
tractions after the cardiac chambers became still. Paralysis of motion set in 
a quarter of an hour after the auricles had ceased to pulsate. The muscles of 
the extremities, an hour after the paralysis of the heart, contracted strongly 
when irritated by an electrical cunrent directly or through their nerves. 

{b) InihiCtuecf Warmblooded AnknaU. 

Experiment 5. — ^After artificial respiration had been established, and the 
heart exposed in a young rabbit, about half a grain of the dried extract of 
dajaksch, dissolved in half a cubic centimetre of water, was injected through a 
small opening in the skin of the left thigh. Before administering the poison, 
the cardiac contractions were noticed to be of normal strength, and 100 per 
minute. Half an hour later the above dose, seeming not to affect the heart, 
but having caused only a ft^quent passage of fteces and urine, and reflex move- 
ments of the body, another dose of half a grain was administered. Immedi- 
ately after the exliibition of the second dose, the peristaltic motion of the 
intestine was marked, and the reflex movements of the limbs were strongly 
developed. Ten minutes later the cardiac pulsations were observed to faie 
slower and more feeble than at first. They next became irregular, both as to 
duration and synchrony, and then the ventricles exhibited vermicular contract 
tions, passine from their apex to their base. Twenty-eight minutes after the 
second dose nad been given, the cardiac chambers were noticed, all at one and 
the same moment, to cease pulsating ; and after a pause the auricles resumed 



132 DR BRAIDWOOD ON THE [AUG, 

their contractionB, whereas the yentricleB remained motionless and not re- 
excitable. The aaricular pulsations were slow, feeble, and at first regular, 
but by degrees they became irregular. The auricles ceased to pulsate about 
half an hour after the ventricles had stopped. Up to this time sensation and 
motion were found unaffected, but by degrees paralysis followed. 

On passing a very strong stream of ^ctricity from a ffalvano-electromotor, 
about t^ee quarters of an hour after the auricles had ceased to pulsate, 
through the muscles of the extremities, they were found to contract (but not 
stronffly) when directly irritated ; but they did not contract at all when elec- 
trically excited through their nerves. Electricity did not produce the slightest 
ventricular contractions, whereas the auricles contracted readily under the same 
influence. The auricles continued for half an hour longer to be excitable by 
electricity, though to a less and less extent, and then they lost this property. 
The intestines could not be excited to peristaltic action by the use of an elec- 
trical current. The voluntary muscles of the extremities retracted when iiicised. 

Remark, — ^In the above series of experiments an autopsy was made in each 
case, with the same results as previously. 

C. ExperimerUa promng negatively the Action of the Poison through 
the Cardiac Branches of the Sympathetic. 

Experiment 1. — Having ligatured the left femoral artery of a frog, I gave 
subcutaneously a large dose of the poison, without exposing the heart. 

The usual general symptoms of restlessness, reflex movements of the limbs, 
contracted pupils, convulsions, and general paralysis were noticed. 

On opening the body, the heart was found m the same condition as in previous 
experiments. The muscles of both hinder extremities were found to be equaUy 
excitable on the application of an electrical stream, directly and through the 
sciatic nerves ; as also on being irritated directly and indirectly by mechancial 
means — showing that this poison does not act airectly through the circulation 
as woorara does. 

Experiment 2. — After exposing the heart of a frog, administered to it a 
common dose of a watery solution of woorara. Paralysis of the voluntary 
muscles having been as usual produced by this poison, but the heart's pulsa- 
tions being found to be 36 per minute, regular, and of normal strength, a dose 
of dajaksch was next injected subcutaneously into the left thigh. 

Fifteen minutes after this latter injection, the ventricles and auricles were 
observed to pulsate non-synchronously, and the ventricular contractions to be 
peristaltic, passing from apex to base. Four minutes thereafter the auricles 
were found contracting twice as often as the ventricle. Three minutes later 
the ventricle was not contracting any more, but exhibited a hi aving movement 
of its walls. In ten minutes more the ventricle ceased to pulsate. About 
half-an-hour after the ventricle became passive, the auricles also ceased to 
pulsate. The general symptoms followed the same course as in experiments 
on healthy frogs. 

Experiment 3. — Having broken up the medulla oblongata of a frog with a 
needle, exposed its heart, and found the cardiac pulsations to be 32 per minute, 
regular, and of normal strength, a dose of dajaksch was administered subcu- 
taneously. Six minutes after the exhibition of the poison the cardiac contrac- 
tions were noticed to be irregular and feeble. The auricles contracted twice as 
often as the ventricle ; but on gentle irritation both sets of chambers pulsated 
synchronously. Five minutes later the ventricle ceased to contract, ana heaved 
only ; and in a few minutes thereafter it was motionless. About half an hour after 
the exhibition of the poison, and a quarter of an hour after the ventricle had 
ceased to pulsate, the auricles became motionless. Then the froe was released, 
and jumped briskly about. The general symptoms followed in tne usual order, 
and in rather more than an hour after the administration of the poison, the 
animal was dead. 

Remark, — ^These last two experiments oppose the supposition of the para- 
lysis of the heart being produced by the poison acting on the vagus. 



1864.] PHT8I0L0QICAL ACTION OF DAJAK8CH. 133 

Cwiduding BemarJca. — Owing to the small amount of the poison 
which was at mj disposal, the above researches are not so complete 
as might be desirable : and a very important element wanting in the 
above sketch is a prefatory notice respecting the natural history of 
this interesting poison \ but this is not as yet attainable, the poison 
being comparatively, if not aoite, new. The peculiar action of 
dajaksch on the heart may recall the well-known j ava arrow poisony 
Upas Anthiar. But these two poisons, though perhaps allied in 
their natural history, differ in other respects from one another. 
Upas Anthiar is properly a Java poison, and, if met with in BomeO| 
it IS only found and used there to a slight extent ; whereas dajaksch 
is the name of a well-known native tribe in Borneo. In chemical 
characters these poisons show themselves also not to be one and the 
same. Lastly, tnese poisons seem to differ from one another in the 
physiological effects they produce on the animal organism. For, 
as Professor Eolliker ot Wlirzburg stated, as the result of his 
investigations, in a paper read before the Medical Society of 
WUrzburg in 1857, Upas Anthiar produces paralysis of the heart by 
acting directly on its muscular fibres ; whereas dajaksch produces 
cardiac paralysis by acting on the sympathetic ganglia of the heart. 

Physiologists have now, seemingly, two separate means of pro- 
ducing that wonderful and interesting phenomenon of a living animal 
with an immovable heart; but they are required also anew to 
unravel this problem, — Wherein consists the death of an animal, or 
what is the boundary between life and death ? 

I have much pleasure, at this time, in tendering my grateful 
thanks to Dr Rosenthal, Professor Du Bois-Beymond's assistant, 
for his aid while making the above researches. 



Abticle V. — Case of Rupture of the Uterus^ in which Gfaetrotomy 
vHu SueceesfuUy Performed, By R. W. Cbiohton, M.D.Edin. 

Mrs M.. 8Bt 28, had been three times delivered by the forceps 
previously to her present confinement. On all of these occasions the 
children had survived birth only a short time, on account of the 
strong compression that was necessarily applied to the head to 
efiect delivery. 

Having attended her during her last confinement, and ascertained 
from the great projection of the promontory of the sacrum, that it 
was impossible to deliver her of a living child at the full term of 
utero-gestation, I advised her in future to have premature labour 
brought on between the seventh and eighth months. 

Her ordinary medical attendant, Mr Davenport of Hayfield, 
finding, during the early part of last winter, that she was again 
pregnant, had strongly urged on her the necessity of this proceed- 
ing; but, from some cause or another, his intentions were not 



134 DR cbighton'b case of bupture of the uterus, [auo. 

carried oat. On the 28th of Jannaiy last, about 2 o'clock A.M., 
I received a note from Mr Davenport, requesting me to come as 
quickly as possible to Mrs M., as he wished me to applj the long 
forceps. I arrived about 4 A.M., and found that rupture of the 
uterus had occurred about two hours previously. The patient was 
rather flushed, and had an expression of great pain and anxiety ; 
pulse 120, of fair strength. As the least pressure caused great 
suffering, I could not ascertain the exact position of the child, but 
the unequal, nodulated surface of the abdomen, the complete reces- 
sion of the presenting part, the free discharge of blood from the 
vagina, and the total cessation of labour pains which had previously 
been very severe and constant, left no doubt as to the occurrence 
of rupture of the uterus, and the escape of the child into the cavity 
of the abdomen. 

The patient stated that during the last severe pain she had, she 
felt something give way with a distinct snap. 

Mr Davenport informed me that she haa been in strong labour 
since 10 p.m. on the previous day ; and that, before my arrival, he 
had made two unsuccessfrd attempts to deliver, first by applying 
the forceps, and subsequently by turning. After the last measure 
had failed, he gave a liurge opiate, as the pains were very severe, 
and it was during one of these that the uterus gave way. 

I explained to the patient and her relatives that the only pros- 
pect of saving her life was by extracting the child througn an 
incision in the abdominal wall ; but, notwithstanding my urg^ing 
them as 8tTonel;jr as I could to have it performed at once, I £uled 
in obtaining their consent. I left the patient most reluctantlv, and 
ordered her half a grain of muriate of morphia every two hoois. 
About 2 P.M. I received a note from Mr Davenport stating that the 
patient and her friends were anxious to have the operation per- 
formed. I arrived about 4 p.m., and found her in great agony, but 
with the pulse of wonderiully good strength. 

After administering chloroform, Mr Davenport introduced the 
catheter, and drew off about a pint of bloody urine. I now care- 
frdly examined the abdomen, and found the child lying with its 
head downwards, resting on the firmly contracted uterus. Before 
operating, I pointed out to Mr Davenport the emphysematous con- 
dition of the cellular tissue over the hypogastrium, distinct crepita- 
tion being both felt by the hand, and heard through the stethoscope. 
I made an incision in the middle line horn below the umbilicus to 
within an inch of the pubes through the skin and cellular tissue ; 
the peritoneum was opened at the upper part, and the incision 
downwards completed with the knife resting on the forefinger of the 
left hand. About a pint and a half of dark-coloured bloody fluid 
escaped, and the child ^ was at once seen lying in the position above 
mentioned. It was removed without any difficulty, and also the 
placenta, which was loose under it. 

^ The child was afterwards weighed, and found to be 9i lbs. 



1864.] IN WHICH GAOTBOTOMT WA8 PERFORMED. 135 

The utenifl was seen to be well contracted, the line of rnptnre 
being almost directly transverse about the junction of the bodj with 
the cervix, and covered bj a layer of coagulated blood. 

Several large clots were removed, and some bloody fluid sponsed 
out, but much disturbance of the viscera was carefully avoided. 
There were no signs of inflammation of the peritoneum except at 
one point in the left iliac fossa. 

Tne edges of the wound were accuratelv brought together by 
twisted sutures on long acupressure needles pasMd through the 
peritoneum. Warm-water dressine on pledgets of lint were applied, 
and a bandage was passed round the abdomen. 

The patient remamed under the influence of chloroform for half 
an hour after the extraction of the child, and on awaking, expressed 
herself as feeling much relieved. 

Pulse 112 ; no sickness ; skin acting fteely. To have one-sixth 
of a grain of morphia every second hour, and two minims of 
hydrocyanic acid, with a little alkali. 

No nutriment was allowed except occasionally a tablespoonftd of 
cold toast-water, or arrowroot gruel. I saw her daily for the first 
twelve days, along with Mr Davenport (whose intelligent care and 
attention were unremitting), and snail give a condensed report of 
the progress of the case, as I find it in my note-book. 

29/A Jan. — Has slept a great part of the ni^ht, and expresses 
herself as feeling very comibrtable. No flushing ; pulse 108, of 
eood strength ; has made an effort to vomit ; about half a pint of 
dark-coloured urine was drawn off by the catheter ; abdomen not 
much distended ; moderate tenderness on pressure. Wound looks 
well ; edges in correct apposition, except at one point below, where 
bloody fluid escapes on slight pressure. Fresn pledgets of lint 
were applied, and the same medicines and diet continued^ with the 
addition of a solution of chlorate of potash for drink (gr. iv. to Ji-)) 
and small portions of ice occasionally to relieve thirst 

30t&. — Has had pain during the night in the region of the liver 
and right shoulder, for which eight leeches were applied by Mr 
Davenport with subsequent relief; urine twice drawn off since last 
visit, clearer, about half a pint each time ; pulse 112 ; tongue 
covered with white fur ; jaundiced tint of skin and conjunctivae ; 
vomited once durine the night some brownish-coloured fluid ; dis* 
charge from vagina less ; wound looks well, seems uniting : abdomen 
not much distended except at the epigastrium and right nypochon- 
drium. Ciontinue water-dressing to wound ; to have an enema of 
warm-water immediately, and another in three hours, if first does 
not act ; turpentine epithems to be applied to the epigastrium and 
right hypochondrium. If the stomach is not irritable, ten minims 
of the muriated tincture of iron to be substituted for the hydrocyanic 
acid. Continue toasl^water, etc. 

31«t — Has passed a good night ; slight sickness once, but only 
A small quantity vomited ; urine thrice drawn off since last visit, 



136 DR CRIGHTON'S case of rupture op the uterus, [AUG. 

lighter coloared and more copious ; abdominal distention not much 
increased, except at epi^trium ; jaundiced colour less marked ; 
pain in right hypochondnum gone ; tongue moist, cleaner ; respira- 
tion nearly natural ; pulse 108, of good strength ; bowels have not 
acted, though she had an enema twice. Wound seems firmly 
united except at one point below, where the edges are slightly 
gaping. Four needles removed ; no opening of line of incision ; 
pads applied with warm-water dressing and a banda^. An 
enema to be given immediately, another in the evening, if first in- 
efiectual; if still no evacuation, gr.v. Hyd. c Cretft, with gr.x. 
bismuth. The enemata failing, the powder was given, and soon 
afterwards the bowels acted freely ; great sickness, however, soon 
followed, bursting open completely the line of wound in its whole 
length. Slight haemorrhage occurred from the wound, but not from 
the peritoneal cavity. Mr Davenport reintroduced several needles 
with twisted suture, and applied straps of adhesive plaster. The 
hydrocyanic acid was given more frequently. 

Ist Peb.y 8 A.M. — Colour of skin much improved, jaundice nearly 
gone ; has slept two hours since the sickness ; tongue cleaner and 
moist ; complains of feeling great distention of the aodomen, which, 
however, is reported as being less than during the night; pulse 
120, firm ; urine drawn off several times since last visit, reported 
copious ; plasters partially removed, so as to examine the wound, 
which is seen to be without any gaping of its edges, but not so 
accurately in apposition as before the vomiting ; has retained the 
beef-tea since 11 p.m. To have tincture of iodine painted over the 
epigastrium and right hypochondrium, turpentine to be reapplied if 
required. Continue prussic acid, with ice, etc. ; beef-tea in small 
quantities to be given by the mouth, and, every four hours, a teacup- 
ful, with ten minims of the muriated tincture of iron, by the rectum. 

2d. — Has passed an uneasy night; vomiting again occurred 
about midnight, with pain in the region of the liver, ror which four 
leeches were applied, with relief; has not vomited since; bowels 
acted well during the night ; has taken about a pint and a half of 
beef-tea since yesterday — the greater part by the rectum ; prefers it 
now by the mouth ; tongue moist, and nearly clean ; countenance 
of natural colour; expression good; pulse 130, of fair strength. 
Straps of adhesive plaster removed, and fresh ones applied ; wound 
has a tendency to open superficially, but not in its whole depth, 
except at one point below, from which dark-coloured fluid escapes ; 
abdominal distention less, except at epigastrium ; tenderness on 
pressure lessj urine reported paler coloured, and more copious, 
drawn off thrice since yesterday. Two long needles substituted for 
two shorter ones, and twisted suture applied. Continue warm- 
water dressing; painting with tincture of iodine, and the other 
medicines. A pint and a half of beef-tea to be given during the 
twenty-four hours. 

^. — Bowels have acted five or six times during the night ; an 



18G4.] IN WHICH GASTBOTOXT WAB PERFORMED. 187 

opiate wasriven by Mr D. at 6 A.if. ; ainoe then the diarrhoea haa 
ceased. Tongue moist and clean; jaundice quite gone; urine 
oopiouB and ciear^ drawn off thrice ; araomen much re£iced in naeu 
except at epispastrium; pressure well borne; pulse 112. Wouna 
dressed as before ; healing at upper and lower pomts ; edges separ- 
ated for about three inches betweoi ; free discharge of dark-coloured 
fluid from the cavitj of the peritoneum^ with strong foetor. Ordered 
two teaspoonfhla of brandj every two or three hours, with one 
quart or beef-tea ner daj. A solution of carbolic add to be 
sprinkled on the beo. 

4ei. — ^Has passed a good night ; no action of the boweb, except 
the frequent passage of flatus per anum; pxdse, 112. soft; wound 
dressed as before ; no tendency to unite in the middle ; all the 
needles removed ; discharge free and very offensive. Continue the 
application of the iodine, and the other medicines, etc. 

6^ — ^Has had a restless ni^ht, and slept but little, although two 
opiates were given ; has had intense pain in the epigastrium and 
left hypochondrium, which was relieved by hot fomentations; at 
the same time experienced great pain and difficultjr in swallowing; 
pulse rose in the night to 144, and is still 140 ; urine drawn off as 
usual ; no action of bowels, except the free passaee of flatus. Haa 
taken little by the mouth since yesterday, but nad an enema of 
beef-tea, with brandy. The cardiac region was carefully examined, 
to ascertain whether the dysphagia mi^t be occasioned by efitision 
into the pericardium, but no signs of fluid there were discovered. 
To have an enema of beef-tea and brandy every three or four 
hours. Wound, dressed as before, is now discharging pus freelv ; 
a cloth wet with a solution of caroolic acid to be applied over tne 
pubes, and changed frequently; this seemed to destroy the fcetor 
very thoroughly. 

6th, — Has had a good night ; general symptoms improved ; pulse 
120 ; wound, healing above and below, still gapes in the miadle ; 
can now take the iron every three hours, ana swallows better. 
Continue the beef-tea and brandy, with a little milk occasionally. 

7tk. — ^Was much troubled during the night with pain in the left 
hypochondrium, which is more distended than yesterday ; bowels 
acted freely this morning after an enema ; passes flatus freely per 
anum ; complains much of a sore over the sacrum, which has been 
dressed regularly for some days past with calamine cerate ; appears 
more irritable and desponding than she has done before ; pulse 120 ; 
wound discharging healthy-looking pus, is contracting. Continue 
iron, etc. 

8th. — Vomited once since yesterday, after taking a dose of the 
muriated tincture of iron, which was, therefore, discontinued for a 
time ; had ai^ opiate twice during the night, and slept well ; ex- 
pression much improved ; pulse 120, of better strength ; distention 
of epigastrium and left hypochondrium less, and pain there much 
lees acute ; pressure over abdomen generally well borne. While 

▼OL. X.— NO. n. 8 



138 DR cbiohton's case of bufture of the uterus, [auq. 

dressing the wound, its edges were rather widely separated about 
the middle, and what was considered the lower edge of the trans* 
Terse colon was distinctly seen at its upper part ; no tendency to 
protrusion of any part ot intestinal canal. Straps of plaster were 
reapplied more firmly than before, and the edges brought into exact 
apposition with diy lint and a bandage round the abdomen. To 
have an occasional dose of hydrocyanic acid and another enema ; the 
iron to be tried a^in in doses of five minims ; beef-tea, etc., as 
before. After the dressing she expressed herself as feeling very com- 
fortable, and for the first time said that she had some hope of recoyery. 

9th, — Has had a good night ; no vomiting since yesterday, though 
she has felt sick occasionally. Pulse 120 ; tongue drier, slightly 
brown; distention of abdomen gradually diminishing. Wound 
united for upwards of two inches ; discharges healthy pus ; still a 
tendency to open widely at upper part: dressed as before, and 
calamine cerate applied to the pubes, as tnere was some eiythema 
from the discharge. Has not taken the iron since yesterday ; to 
have instead, the prussic acid, with a little soda, m infusion of 
calumba ; beef-tea and brandy as before, and bread and milk occa- 
sionally, of which she is veiy fond. 

11th. — ^Appearance much improved since last visit; pulse 112, of 
good strengtn : slept during past night firom 11 P.M. till 5 A.V. ; 
no vomiting ; Dowels have acted several times ; has passed water 
by the natural efforts ; appetite better ; tongue clean and moist ; 
distention of abdomen less; wound contracting, though still open 
to the extent of two inches ; erythema over puoes less. Plasters, 
etc., reapplied ; has taken the iron regularly yesterday and to-day ; 
to have, at her own request, a small mutton-chop. 

18^. — Has improved steadily since the date of last report ; sleeps 
well ; tongue clean and moist ; bowels opened by occasional 
enemeta; pulse about 100, of ffood strengtn; size of abdomen 
much reduced, no tenderness. Edges of wound well together under 
the plaster ; when this removed but little tendency to gape, except 
at tne upper part; is evidently healing kindly; a little healthy 
pus at the lower angle. Takes half a grain of quinine several times 
a-day ; has had for some days beef-tea and mutton-chop, with a 
little fish occasionally. After dressing wound she felt so well as to 
express a desire to get up soon; can now pass water regularly 
without the catheter. 

22dl — Continues to improve; pulse 98; bowels^ opened by 
enemata; appetite has failed considerably for past two or three 
days, notwithstanding the administration of half a grain of quinine 
every four hours; abdomen now quite flat^ no tenderness; on 
removing plasters, the wound found quite united ; a free discharge 
of pus from the vagina replaces that from the wound ; no foetor. 
Ordered the same doses of quinine, dissolved in ten minims of the 
muriated tincture of iron ; to have porter fr^uently, up to a pint 
a-day, and as much animal food as the stomach will digest. 



1864.] IN WHICH GASTBOTOMT WAS PERFORMED. 139 

From this date she continued steadily to improve till 3d Marchy 
when she had a rigor, with pain in the left iliac fossa ; bnt after free 
action of the skin, and the reapplication of the iodine, she began to 
imnroTe anin in a few days. 

On 24u March the pnlse rose to 120, and slight jaundice 
appeared, with increased dolness in the ri^ht hypochondrium. 
Tincture of iodine was painted over the dull space, and nitro- 
muriatic acid given internally, and in the course of two or three 
days she was so much better as to be able to be lifted out of bed to 
' the sofa for several hours at a time. 

During the first week of April she was strong enough to sit up 
daily, and was so well on my visit to her on the 4th of that month, 
that 1 discontinued my attendance. She mentioned that the menses 
had appeared a day or two previously. 

On 2d June, she walked nom HajdSeld to my house, a distance of 
four and a^half miles (returning again the same evening on foot), 
and assured me that she had not been in better health for years. 

BemarlcB. — The careftilly compiled statistics of Dr Trask, of 
New York, give great encouragement in undertaking the apparently 
hopeless operation of ^trotomy in cases of rupture of the uterus : 
yet, since the date of the publication of these (1856), I cannot fina 
any successftd case recoraed as having occurred in Great Britain. 
I have, during the past thirteen years, seen only' one case in addition to 
that recorded above. In that case the practitioner in attendance was 
not aware that rupture had occurred, and did not folly sanction my 
proposal to perform gastrotomy. The patient was abandoned, and 
died undelivered about thirty-six hours after the occurrence of rup- 
ture. She was a primipara, and apparently free from pelvic deformity. 
Ergot had been given freely dunng the progress oithe labour. 

in Mrs M.'s case several points deserve, 1 think, especial notice ; 
the long interval that occurred between the rupture and the extrac- 
tion of the child — fourteen hours ; the recovery from acute iaundice 
occurring in the circumstances; and the apparently good effects 
of the application of the tincture of iodine extemsuly in causing 
absorption of the products of inflammation affecting the serous 
covering of the different abdominal viscera. 

Chafel-kn-le-Fritb, June 10, 1864. 



Article VI. — Twdve Cases of Ovariotamy. By Thomas Keith, 

i .H.C.S.£j. 

In July 1863, I read before the Edinburgh Medico-Chimrgical 
Society an account of the first successful cases of ovariotomy iper- 
formed in Scotland since Mr Lizars' single and partial success in 1825. 
The subjects of these operations have remained in perfect health. 
One married eight months after the operation, and the others have 



140 CA8E8 OF OVARIOTOMY BY DB KEITH. [AUG, 

sinoe performed the usaal duties of home life ; while one, twenty- 
seven years of age, in whom the weight of the tumour removed, 
now a year and a half ago, was upwards of one hundred and twenty 
pounds — the largest tumour, by far, ever removed successfully 
from the living body — ^is now a strong healthy woman. It is now 
proposed to continue an account of all the operations for ovarian 
disease which I have since then performed — successful as well as 
unsuccessful — in the order in whicn they occurred. And I wish it 
to be understood that these cases are fair cases ; for I have not 
removed small tumours, and I have invariably declined operation 
in cases in which the general health was very good and the disease 
the source merely of inconvenience, and not of danger to life. But 
I have not felt warranted in declining a single case — however large 
the tumour or however much reduced the strength of the patient 
— in which there was even a bare probability of success, although 
by operating on very large tumours, or in desperate cases, one, of 
necessity, risks both the credit of surgery and one's own reputation. 
In one case I saw last year, and again a few months ago, interference 
with the tumour was not recommended, on account of its extensive 
and intimate connexions with the uterus^ bladder, and rectum. I 
have lately declined other three cases in which I was asked to 
operate; but in all of them the disease had nearly reached its 
natural termination. Of these, one died within forty-eight hours, 
another within a week, and the third within three weeks after 
being first seen. It would have been simple foolhardiness to have 
expected, that in such extreme cases nature would give one any 
assistance, in sustaining the shock, or repairing the injury necessarily 
inflicted by such a severe proceeding as ovariotomy must always 
be in large tumours. All of these cases, however, had been most 
favourable for removal only a few weeks or months before. With 
these exceptions, I have declined no case where the tumour 
was capable of being removed. It is only fair to add, that since 
I commenced these operations, nearly two years ago, I have de- 
clined operating in nine cases, in which the general nealth was not 
interfered with, and life not yet threatened by the disease, on the 
ground that I was not justified in recommending, and the patient 
not warranted in undergoing, such a formidable operation. Oi these, 
I regret to say, three at least have died. Two oied in the country, 
after a first tapping to facilitate their journey to town; while 
another case — ^a very sad one — who came to me first about eighteen 
months a^o, I declined, though a most favourable case at that time 
for operation, on the ground that the tumour was merely an incon- 
venience to her. She was very anxious to have it removed, and I 
agreed to do so as soon as her general health became much afiected 
or her life in danger. She left disappointed, went home, had the 
cyst injected with iodine, suffered a ^at deal of pain for several 
days after the injection, returned in a few months, larger than 
ever, with her general health much impaired, and asked me now tr 



X8e4.] 0A8E8 OP OYARIOTOMT BT l>E KEITH. 141 

fidfil m^ promisei and remore the tamoar. Bat I waa now obliged 
to decline a second time, on account of the adheaiona that had 
fonned in the pelvia after the infection of iodine into the cyst. 
These were of such finnneaa that the removal of the tunoor would 
have been impossible. 

The average weight of the tumoara removed was a little over 
42 lbs. ; the average of the fatal cases npwarda of 60 lba.| while 
that of the sucoessrul cases was 39 Iba.^ or. excluding the veiy 
large tumour, a little upwards of 31 lbs. Adhesions, generally ex* 
tensive and often of great firmness, were met with in all tlie cases 
except three, and these three recovered without the slightest on* 
favourable symptom. And, thoueh equally jhvourable recoveriea 
occurred in some cases where adhesion was great, in not a few a 
successful result was got with great difficulty, and after a long and 
tedious convalescence, with more or lees suppuration in the pelvis. 

In the following case an attempt was made, towards the natural 
termination of the disease, to save the life ol one of the most re- 
markable women I ever met. She had been repeatedly tapped, 
and I had in consequence to deal with unhealthy blood, and with a 
nervous system enfeebled by long and great suffering, and if the 
attempt was a failure, and her life was thereby shortened by a few 
months, the unfortunate termination seemed after all to have arisen 
from rupture ofj and hsBmorrhage fit>m, the ovary that was left, and 
which at the time of the operation was apparently in a healthy state 
— one of those accidental and unforeseen circumstances that every 
now and then must arise after all capital operations. 

Case I. — MuUtlocuJar Ovarian Tumour j weighing nearly 80 lbs. 
Ovariotomy. Death on the second day. 

In the end of May last. Dr Thomson of Dalkeith asked me to see 
a married lady, twenty-tnree years of age, who had just come under 
his care. She had made a long railway journey the dav before, and 
was in consequence much fatiraed. She was so emaciated, and looked 
so exhausted, that the idea of interfering with the tumour in anv way 
seemed out of the question. The aUomen was occupied by an 
enormous multilocuhu: tumour, and she measured upwards of fifty 
inches at the umbilicus. 

The disease had been detected when she was seventeen vears of 
age, a few months before her marriage. Its progress was slow, her 
health continued excellent, and after the nrst tapping no solid 
matter was felt, and she was soon able to be about again. The 
tappings went on, however, the intervals steadily shortening by 
one-half, and now, afl;er each time an increasing mass of solid 
matter was felt, and her sixe diminished less and less. Till the 
last tapping, three months ago, her general health bad remained 
unaffe(Aed ; but since then she had not rallied as she used to do, 
and had been quite an invalid. She suffered greatly from neural- 
^c face-ache and pain in the right side over the semi-solid part of 



142 CASES OP OVARIOTOMY BY DR KEITH. [AUG. 

the tamoor. She had lost flesh very much, took little food, and 
lived mostly on stimulants. 

She required tapping about a week after this. Upwards of 50 
lbs. of thick fluid were removed. The tumour consisted of one 
enormous cyst, with a large semi-solid mass occupying the right 
side, extending under the ribs. The tumour was unattached in 
the pelvis, but the large cyst did not subside much. A few days 
after this tapping she was seized with phlegmasia dolens of the left 
leg. She suffer^ severely, but in three weeks she was able to be 
up again. She was put upon full non-stimulating nourishment, 
her general condition improved, and she gained flesh ; while the 
tapping, which was looked for in six weeks, was delayed for 
uj)waras of three months. It became necessarv, however, by the 
middle of August, and upwards of 50 lbs. of fluid were again re- 
moved. I was not aware at the time of the tapping that the period 
had not quite passed over, and she was scarcely laid on her back 
when she was seized with an intense pain in the right groin. She 
said she was sure something had given way. The pain was most 
acute, and for two or three days she was very ill, with all the 
symptoms of peritonitis. She had great abdominal tenderness, and 
a rapid pulse. In a week, however, she was again up, and then, 
for tne first time, she spoke to me of the chances for and against 
her after ovariotomy. She knew she could not now have an 
average chance, but still there seemed a reasonable prospect of 
success. 

The tumour was accordingly removed on the 27th of August. 
There was slight parietal adhesion in front, and the omentum was 
wound around ana adherent to the semi-solid portion of the tumour 
over a great extent, but there was no difficulty in securing the 
vessels, and but little injury done in its separation. The mass of 
semi-solid matter was, however, very large. It extended under 
the ribs on the right side, over the upper part of the abdomen, and 
across to the left side. Several lar^e cysts were tapped, ana the 
mass reduced so that it was easily withdrawn. The mass of secon- 
darv cysts and cyst walls weighed nearly 30 lbs., and upwards of 
50 lbs. of fluid had been removed from the largest cyst, about ten 
days before. Before closing the wound the right ovary was drawn 
aside, and some of my friends present remarked what a healthy 
ovary it looked. Satisfied with its small size and natural appear- 
ance, I did not touch it. 

She was put to bed in an excellent state. The night was passed 
quietly, and next morning she had an excellent expression, and 
quiet pulse. About eleven o'clock she suddenlv vomited, and com-* 

f)lained of the same intense acute pain that sne had felt after the 
ast tapping, and said surely something had given way. Her pulse 
be^^an to rise after this; she became chill, and died thirty-eight 
hours after the operation. 
The pelvis was nearly ftill of sero-sanguinolent fluid. On the 



1864.] CASES OP OYARIOTOMT BT DR KEITH. 143 

posterior border of the right ovary were two rapttires — one of some 
standing the other quite reoent. In the one was adhering a de- 
colorized clot ; and this rupture had probably taken place during the 
menstrual period, at the time of the last tapping, ten days before. 
In the other the fissure was recent, and a rery large coagulum 
was adherent in it. 

Case IL — MuUUocular Ovarian Tumour weighing 40 Ibe. 
Ovariotomy. Recovery* 

An unmarried lady, twenty-three years of a^, who had enjoyed 
an average amount of health, had her attention directed by her 
friends, about the middle of July last^o an increase of her size. 
She was seen early in August by Dr JDrummond of Glasgow, who 
found the abdomen occupied by a large ovarian tumour. The for- 
midable nature of the affection under which she laboured, and the 
only remedy for it were accordingly explained by him to her friends, 
but as her life was not then threatened by the disease, no immediate 
interference was recommended. She was advised to live quietly, 
and go for a time to the country. 

A few days after this, when on her way through Edinburgh, she 
was seized with severe abdominal pain, and was imable to com- 
plete her journey. Her distress was farther aggravated by the 
jolting in a cab on her way to a friend's house, and when seen 
shortly after by Dr Warburton Begbie, she was suffering from 
severe peritonitis. The acute symptoms soon yielded to the 
remedies employed, but the tumour enlarged. She suffered so 
severely from the distention, she had such weary sleepless nights, 
and began to lose flesh so rapidly, that on the 21st it became 
necessary to relieve her by tapping, the ^rth at the time being 
nearlv 45 inches. This I accordin^lv did at Dr Begbie's request. 
Nearly four gallons (40 lbs.) of thick ^reen fluid were removed. 
The cyst wwls were felt to be very thick, and were extensively 
adherent to the parietes, while a mass of secondary cysts filled up 
the left iliac region. 

She was much relieved, and in the course of a fortnight was able 
to be removed to Avr. Though she gained strength to a certain 
extent she was unable to walk, but was moved about in a chair. 
The cyst commenced to refill, she increased at the rate of half an 
inch a-day, and in little more than a fortnight she was brought 
back to town nearly as large as before. On the 27th, tapping was 
aeain necessary ; and 35 lbs. of very thick fluid were removed. 
Sue did not, however, diminish so much as after the former tapping, 
for the mass of secondary cysts had greatly increased. 

It was now evident that the disease could no longer be safely 
temporized with, and that it would run its course with imusual 
rapidity. It accordingly became necessary for me to place before 
her in cold statistics, the risks and advantages of the radical cure. 
She had to take her choice between the certainty of a short life, — 



144 CASES OF OVARIOTOMY BT DR KEITH. [AUG. 

and it would have been a very short one, not free from suffering, and 
the chance of a long life after ovariotomj. The operation was at 
once decided upon, and performed on the 29th of September — two 
days after the second tapping. Dr^egbie, Dr Warburton Begbie, 
Dr Craig of Ratho, Dr Sidey, 



and Dr Keith^ were present. There 



were extensive, but recent, parietal adhesions, which gave way 
readily to the hand. The peaicle was short and broad, extending 
about twelve or fourteen inches along the base of the tumour. The 
clamp was applied within an inch of the uterus, and there was con- 
sequently a good deal of strain upon the pelvic tissues ; a trouble- 
some oozing from some torn adhesions to the false ribs on the right 
side delayed the closing of the wound for nearly half an hour; 
otherwise nothing unusual occurred. 

The cyst walls weighed 5 lbs. 6 oz., and 35 lbs. of fluid had 
been removed from the large cyst two days before. 

No bad consequences followed ; and since her return to Glasgow, 
a month after the operation, she has enjoyed excellent health. 

Case III. — Large Semi-aolid Ovarian Tumour. Ovariotomy. 

Recovery. 

In the end of August, Dr Wm. Brown asked me to see a young 
lady only sixteen years of age, in whom an attack of abdominal 
pain had led to the detection of an ovarian tumour, about seven 
months before. Its increase was rapid, and in July last it was 
punctured below the umbilicus, and after passing a sound through 
the cannula, and breaking into several cysts, a considerable quantity 
of very thick viscid fluid was obtained, without, however, much 
diminishing the size or determining at any one point the subsidence 
of the tumour. When I saw her six weeks after, she was nearly as 
large as before. 

This young lady's case is thus described by the author of the 
Excursion Chirur^ioale en Angleierrey who was present at the tap- 

Sing, ^^ Ainsi, j'ai vu une jeune flUe de 15 k 16 ans, dont je vous ai 
4jk parl^, atteinte d'un kyste multiloculaire ^norme k contenu 
visqueux, filant, gris verdfttre, dont la ponction, apr^ avoir vid^ 
diverses poches, ne parvint k determiner le retrait sur aucun point, 
de I'^pigastre au pubis et d'un flanc k I'autre. l^videmment il 

Jaurait eu imprudence k tenter I'extirpation d'une telle tumeur 
ont les adh^rences ^taient si fortes et si ^tendues qu'elles auraient 
emp^chd probablement le chirurgien de terminer I'opdration. II est 
Evident que, dans ces circonstances, Toperation est contra-indiqu^, 
et que la maladie par&it in^vitablement mortelle ; mais c'est un cas 
k rapporter aux coutre-iudications naturelles de I'ovariotomie." 

The abdomen was entirely occupied by a large irregular semi- 
solid mass. There was only one cyst of any size, which occupied 
the enigastric space, extending under the sternum. The ribs were 
alreaay being pushed outwards, and the ensiform cartilage pointed 
slightly upwaras. In the left hypochondrium the tumour bulged 



18e4.] CASES OF OVARIOTOMY BY DR KEITH. 145 

outwards, and felt verj hard and near the skin, which bore the 
marks of former leeching and blistering. She had long suffered 
from severe pain in this region, and here firm adhesion was evident. 
In the right iliac region the tumour felt also very hard and near the 
surface, and here, too, pain had been from time to time complained 
oil The pelvis was occupied hy a solid mass coming below the 
Inrim, and the uterus, though it could not be moved from off the 
tumour, had a sort of rotation upon it, giving the impression that 
the pedicle was verj short, rather than tnat adhesion existed 
between the two. 

She was pale and thin, with a feeble circulation, but her general 
health was still good. She took her food well, slept well, and was 
able to take carnage exercise without fatigue. 

After this she went to the country, and I saw her again on her 
return to town in the beginning of November. Her general health 
continued good, but the tumour had increased in all directions, — 
especially above. The cjst, fiUine the epigastric space, was larger 
and more tense and momment. The ensiform cartilage now pointed 
directly upwards. The ribs were more bulged outwards, especially 
laterally, and the measurement over the lower end of the sternum 
was two inches greater than at the umbilicus. My attention was 
now directed to the state of the spine, for the whole of the lumbar 
and three lower dorsal vertebras were very prominent, rendering 
the curvature of the back so great, that with the bulged condition of 
the ribs she was quite barrel-shaped. 

In hopes of getting some information as to the connexions of the 
upper part of the tumour, I tapped the upper cyst at its lower 
margin, on the 12th November, midway between the umbilicus 
and ensiform cartilage. A large trocar was used, but after a few 
ounces of very dutinous fluid escaped, the stream stopped and no 
more could be obtained, though on passing in a probe it was evident 
the cyst was of considerable size. Soon after, pain came on, and in 
the course of an hour I foxmd her with a pale anxious countenance, 
thoracic breathing, and a very rapid nulse, suffering from intense 
pain and tenderness, with vomiting, all over the upper portion of 
the abdomen. Large opiates and fomentations relievea this, but 
for some days her condition gave rise to not a little anxiety. All 
this time there was a constant oozing, from the puncture, of the same 
gelatinous sticky fluid, and it was supposed that altogether more 
Sian a gallon made its escape. For two or three days there was 
clear sound on percussion, as low as two inches below the ensiform 
cartila^, but by the end of a week this had quite disappeared, and 
the duTness extended as high as before. It was afterwards found 
that the upper cyst had not in the least refilled, but that its posi- 
tion had been occupied by the semi-solid portion moulding itself 
into its place. 

After repeated examinations of the tumour, it seemed to me that 
there was no obstacle to its removal, as far at least as its upper 

VOL. X. — NO. II. T 



146 CASES OF OVARIOTOMY BY DR KEITH. [AUG. 

portion was concerned. But the nature of its connexion with the 
uterus could not be quite satisfactorily determined, while the now 
very great curvature of the spine — rendering it uncertain whether 
this arose from disease of the bodies of the vertebrse themselves, 
or whether it was simply caused by the direct weight and pressure 
of the now almost solid tumour — added greatly to the anxious 
doubts and grave responsibilities of the case. But on the other 
hand, the patient was but sixteen years of age, of a healthy family, 
with young and probably not yet unhealthy blood, and her nervous 
s^^stem as yet not much broken down by suffering or sleepless 
nights. I, accordingly, felt warranted in recommending to the 
patient and her friends, that an attempt should be made to re- 
move the tumour, else there was nothing to be looked forward to 
but a short and miserable life. And as the recent inflammatory 
attack would, in all probability, lead to the formation of extensive 
adhesion alon^ the upper part of the tumour, it was evident that 
this attempt should not be delayed very long. She had lost flesh 
since the tapping, and had not been out of bed. She was not in a 
very good state for the operation, for the tongue was big and foul, but 
there was very little chance of her ever again getting into a better. 
The tumour was accordingly removed on the 2l8t of November. 
Dr Brown was present. Dr Keith gave chloroform, and Dr Keiller 
and Dr James Sidey gave me their usual invaluable assistance. 
The tumour was exposed over a mass of thickened and contracted 
cysts, the result apparently of the first tapping. The opening was 
enlarged sufficiently to admit the hand, which was pushed through 
loose adhesion downwards, and the pelvic cavity examined as tar 
as it was possible to do so. It was apparently free of adhesion, 
but the uterus could not be reached. 3elow the umbilicus the 
adhesions were very loose, and gave way at once to the pressure of 
the hand. Above they were much as was anticipated, being nearly 
universal. These were all gradually separated by the hand ; but, on 
the left side, they were of the utmost firmness, and in breaking them 
down the tumour fissured and gave way in all directions. I was, 
however, totally unprepared for the great mass of solid substance 
that extended under the ribs, for three-fourths of the whole tumour 
lay above the umbilicus, and though I had enlarged the incision up 
to the ensiform cartilage. I am sure I could not have removed the 
tumour entire. A verv large trocar was then pushed here and there 
into it, but only a small quantity of very viscid thick matter could 
be obtained. 1 next cut deep into the heart of the mass below the 
umbilicus, cut wiMi the knife and opened cysts in all directions, and, 
passing in my hand, broke down the inside of the tumour. This was 
not easily accomplished, for the divisions between the cysts — and they 
were all small — were very fibrous and thick, and gave way to the 
fingers very unwillingly. Half a pailful of fluid and broken down 
cysts was thus obtained, but the vascularity of the interior was so 
great, that it was necessary to finish this part of the operation with 



1804.] CASES OF OVARIOTOMY BY DR KEITH. 147 

the Qtmoflt rapidity and with apparent roughness. I succeeded at 
length in dragging through an opening, extending only an inch 
above the umbilicus, a mass of solid matter and cyst-walls, weigh- 
ing upwards of 20 lbs. As this was withdrawn a firm and thick 
band of adhesion arising from the right iliac region came into view. 
It formed almost a second pedicle, and contained large vessels. It 
was transfixed and tied. The pedicle itself now came into view on 
the left side, but the uterus came out with it. The tipper part of the 
pedicle which ran along the tumour up to near the false nbs was of 
great length, but it gradually shortened and disappeared in the 
comer of the uterus which was quite close to the tumour. It was 
tied in four or five divisions, for the clamp could not be got under 
the tumour and the mass cut away. The clamp was then applied 
round the long part of the pedicle, and an attempt made to tie the 
vessels singly in the portion which was connected so closely with the 
uterus ; but after tying two large vessels, there was so much oozing 
that I reluctantly embraced the whole in the clamp, brinring the 
uterus in consequence against the abdominal wall. When the 
bleeding from the torn adhesions had ceased, the clots were removed 
and the pelvis sponged out, and the omentum, which was of very 
great size, was carefully spread by the fingers over the intestines, 
and especially over the left side where the adhesions had been 
strongest, ana where the tendency to ooze was greatest. The wound 
was then closed by thirteen deep stitches, placed closely together on 
account of the thinness of the abdominal wall. But the elevation 
of the ribs was so great that the cavity of the abdomen remained 
half-filled with air. The ribs were pushed downwards and the air 
pressed out as much as possible alongside the clamp, — a large heavy 
compress of wet lint bemg placed over the wouna and a bandage 
over the ribs to keep them aown and prevent the re-entrance of air. 

She was under cnloroform for an hour and a half. The whole 
proceeding had been one of the utmost severity ; and when the 
pallid, fra^e, emaciated form was lifted into a warm bed, and left 
to nature and an intelligent nurse, it seemed to us all that nature 
had been asked to do too much to repair the injury that had of 
necessity been inflicted. 

But on the sixth day after the operation she felt so well that she 
thought she might be allowed to do a little work. That ni^ht she 
had a slight chill, which, however, seemed to have passed off by 
next day after free perspiration, without doing any harm. The 
seventh night was restless, and in the morning for the first time the 
pulse was rising. There was some abdominal tlndemess, which 
was not relieved by having the bowels moved by enema. By mid- 
day the distention was considerable, and as there was some pull 
upon the clamp, it was removed. This was followed by relief of 
the pain, and to a considerable extent of the distention also. The 
pulse continued to rise, and towards afternoon vomiting came on, 
and though the sutures had been removed some days before, no 



148 CASES OF OVABIOTOMY BY DR KEITH. [AUG. 

harm was done to the freshly united wound by the first attacks of 
vomiting. Some strips of plaster were, however, put on, not that 
they were absolutely necessary, but to give confidence during the 
vomiting. The attacks of vomiting went on every half-hour, and 
were very severe, the pulse having now risen to 150, and her con- 
dition for some hours was most critical The state of the pedicle 
was examined after every attack. It had considerably retracted, 
and there had been some oozing from it, and during every fit of 
retching there was a gush of yellow serum from the abdominal 
cavity. About midnight a large vessel was observed bleeding from 
the stump of the pedicle ; this was at once secured, and the whole 
freely touched with the perchloride of iron. Towards morning 
copious serous discharges came from the bowels, and the vomiting 
then ceased. In a lew days there was decided fulness of the 
recto-vaginal fossa, but as there was now a good deal of discharge 
from the lower end of the incision — at first of a serous oily nature, 
then dirty serous, and then purulent — it was not interfered with, 
but its degree of tenseness careiully watched from day to day. Bj 
the end of the third week the discharge from the wound was copi- 
ous, and continued more or less for several weeks. During all this 
time the pulse continued high, but her recovery — thanks to the 
most careful and intelligent ofuursing — was now uninterrupted, and 
six weeks after the operation she was thoroughlv convalescent. 
She was round-shouldered for some time, and had a considerable 
stoop, but this soon wore off when she began to get out, and the 
spine quicklv regained its normal curvature ; and in a short time it 
was impossible to recognise, in the healthv-lookine blooming girl, 
the subject of all the anxious doubts of a tew mon& before. 

Case IV. — MuMlocular Ovarian Tumour j weighing impounds. 
Ovariotomy. Recovery. 

On the 18th of October last, Dr M^Watt of Dunse asked me to 
see Mrs J., aged fifty, who had sought his advice four months before 
on account of ovarian disease. She was then scarcely able to retain 
any food, and had had several attacks of vomiting of blood. Under 
treatment the vomiting ceased, and her general health much im- 
proved till five weeks before I saw her, when she was obliged to 
take to bed on account of severe abdominal pain which had remained 
more or less ever since. 

She was a very little woman, pale, extremely emaciated, and 
verjr feeble. The pulse was small, and generally about 90. She 
had restless nights 6rom dyspnoea, and could scarcely take any food. 
She measured 41^ inches at the umbilicus. The upper part of the 
tumour was fluid, but frx>m the extremely oedematous condition of 
the abdominal wall it was impossible to make out the state of the 
lower portion. The uterus was central, normal, and movable, but 
the roof of the vagina came very low down, especially on the left 
side. The general condition of the patient was so unfavourable 



1864.] CASES OF OYABXOTOMY BT PR KEITH. 149 

that the idea of operation conld not then be entertained ; bat in 
hopes of giving her some temporary relief, about two gallons of 
fluid were removed from the upper cyst by puncturing it above the 
umbilicus. A large semi-solid mass was now felt to occupy the 
lower and left side of the abdomen below the umbilicus. After 
Bome davs, when the oedema of the wall had somewhat subsided, 
Dr M'^ att was able to make a more careful examination, and was 
satisfied that the adhesions were both firm and extensive. 

Much to our surprise she rallied, and had so fax refined strength 
as to be removed to town in the beginning of January. Ihe 
tumour had nearly regained its former dimensions, and the oedema^ 
tons anterior wall hung down over the pubis, forming a tumour 
nearly the size of the head. 

She got cold on her way into town^ and had an attack of in- 
fluenza, which was prevalent at the time. To relieve the bronchial 
irritation and dyspnoea, she was again tapped, and the oedema of 
the limbs and aodominal wall having somewhat subsided, the 
tumour was removed on the 16th of January. Dr M'Watt of 
Dunse, Professor Stewart of Kingston, Dr Sidey, and Dr Keith 
were present The external incision was extended to two inches 
above the umbilicus. The omentum was Ij^ing between the 
tumour and wall, adherent to both. As the parietal adhesion was 
very firm, I cut through the omentum till the surface of the tumour 
was reached : and fin£ng the adhesion of the omentum less firm to 
the tumour tnan to the wall, I separated it from the tumour to the 
left side till the free edge was reached. It was then freed and 
turned to the right side, but all its parietal attachments were not 
seiMirated. Very firm parietal adhesion existed between the semi- 
solid part of the tumour occupying the left side and iliac region. 
Posteriorly the tumour was embedded in a mass of small intestine 
and mesentery. These adhesions were easily separable, except a 
piece of mesentery, about the size of the palm ot the hand, wnich 
was very firmly attached, and contained large vessels. Lower 
down its connexions were separated along the brim of the pelvis on 
the left side, and a semi-sobd mass was adherent along the side of 
the rectum and hollow of the sacrum. This last adhesion was 
firm, and part of the serous covering of the tumour was torn off and 
remained. Finallv, the mass was turned out after much injury had 
been inflicted on the peritoneum. The pedicle was short, and when 
the calliper clamp was secured outside, from the thickened state of 
the abdominal wall there was a great pull upon the uterus. Part 
of the omentum, which was still adherent to tne pedicle and side of 
the uterus, was separated, and some vessels secured ; still there was 
a good deal of oozing coming up apparently from the torn pelvic 
adhesions. This was found at last to come from a fissure m the 
pedicle immediately below the clamp. The clamp was accordingly 
removed and readjusted, and the bleeding point secured. The 
wound was then tightly closed by a number of deep stitches in 



150 CASES OF OVARIOTOMY BY DR KEITH* [aUG. 

anticipation that the oedematous state of the wall would subside in 
a few hours. 

There was a good deal of shock. She passed a restless night, 
and next morning there was so much distention from flatulence that 
the head of the clamp was buried in the wound, and the handles 
standing up at nearly a right angle. These unpleasant symptoms 
disappeared shortly after giving her some simple food. By the 
end of the third day the stitches were lying loose and were removed, 
as was also the clamp, the wound bein^ quite united throughout. 
On the ninth day she was removed during the day to the nurse's 
bed, and was walking through the room by the end of the second 
week. She returned to Dunse, a distance of fifty miles, in the 
midst of a snow-storm on the twenty-fifth day after the operation. 
Since then she has enjoyed the best of health. 

Case V. — MultUocular Ovarian Tumour^ toeighin^ 37 lbs. 
Ovariotomy. Death, on the sixth day, from Pentonitta. 

M. B., aged forty, a tall, thin, sallow-looking woman, unmarried, 
was sent to me last autumn by Dr Wilson. She had an ovarian 
tumour of five months' growth, which already nearly reached the 
ensiform cartilage, but as it had not yet given her much incon- 
venience beyond what arose from its bulk, I recommended her to 
let it alone* Her girth then was 37 inches. 

She returned in four months. She was now 42 inches at the 
umbilicus ; the tumour had nearly doubled in size, and she had lost 
much flesh. She was now unable to do anything for herself, was 
be^nning to have restless nights, and suffered from pain in the 
epigastrium, while the lower extremities were distended almost to 
bursting. There was also great oedema of the loins and abdominal 
wall, as high as the umbilicus ; there was no albuminuria. 

She haa lived a very sedentary life, and some years before had 
been confined to bed for nearly twelve months with subacute 
rheumatism, which had left her hands slightly deformed. She was, 
moreover, the only surviving member of her family, all of whom 
had died early, mostly of phthisis. Her general condition was 
thus not a very favourable one for ovariotomy ; still the case seemed 
a fair average one. 

She was tapped in the end of January. Twenty-three lbs. of 
thick fluid were removed from a large cyst which composed the 
lower half of the tumour. The upper portion of the tumour did ' 
not in the least subside, and a large semi-solid part continued to 
occupy the upper half of the abdomen. The oedema of the limbs 
soon subsidea, but the cyst began at once to refill. 

The tumour was removed on the 7th of February through an 
opening just sufficient to admit the hand. The lower cyst was first 
tapped, and the upper cysts were emptied through the larger one. 
There was parietal adhesion, easily separated by the hand, from a 
little above the umbilicus upwarcb over the epigastrium. As the 



1864.] CASES OF OVARIOTOMY BY DR KEITH. 151 

mass of cyst-walls, weighing upwards of 6 lbs., was being withdrawn 
through rather a small opening, one of the cysts gave way, but 
none of the contents seemed to get into the abdominal cavity. 
There was no bleeding, no exposure of the intestines, and the 
operation was completed in a few minutes. There was a slight 
pull upon the uterus when the clamf) was secured outside, but not 
nearly so much as I had 6ften met with before. The wound was 
closed by deep and superficial silk sutures as usual. 

She vomited very severely as she came out of the chloroform, 
and complained all afternoon of intense sickness, with burning at 
the epigastrium. B^ evening she was suffering severeljr fipom 
flatulence, which continued all night, preventing sleep. This con- 
tinued to a most distressing deeree, with a constant overpowering 
feeling of sickness. By the end of the second day, there was some 
distention of the upper part of the bowel, which went on increasing. 
The pulse also began to rise. The clamp was removed on the 
third day. and a good deal of yellow serum followed its removal, 
without, nowever, affording relief. I could not satisfy myself that 
there was any accumulation in the pelvis from the examination of 
the recto-vaginal fossa. She died on the morning of the sixth day. 

The small intestines were found all glued together by recent 
Ijrmph, pretty well or^nized ; and in the i)elvis, which was com- 
pletely shut off from the rest of the abdominal cavity, there was 
about half a pint of dirty thin peasoup-looking fluid, with flakes of 
lymph, showmj; the low form of abdominal inflammation. The 
wound was (][uite healed, and the peritoneal line of incision could 
scarcely be distinguished. I had allowed the silk sutures to remain 
in all tne time the patient lived. She died on the morning of the 
sixth day, and there was no matter lying along their tracks. It 
would appear, therefore, that in this case at least^ the silk suture 
answered all the purposes that the admirers ot the wire suture 
claim for it. 

Case VI. — Unilocular Ovarian Tumour. Ovariotomy, Recovery. 

In April last. Professor Christison asked me to see a married 
lady about fifty years of age, who had laboured under ovarian dis- 
ease for upwards of twenty years. The tumour had been of very 
slow growth, and had scarcely affected her general health till about 
the time I saw her. The abdomen was occupied by a large single 
cyst, and the contained fluid felt so thin and so near the surface 
that but for the history, it would have been impossible to tell 
whether it was ascitic or ovarian. There was slight oedema of the 
limbs, and she was thin ; otherwise her health was good. 

Three months afterwards the tumour had considerably increased, 
there was also greater oedema of the extremities, she was unable to 
lie down at night, and the heart was beginning to beat above its 
normal level. It was accordingly agreed to remove the cyst ; but, 
before doing so, I emptied it, and as the fluid was clear, of low 



162 CASES OP OVARIOTOMY BY DR KEITH. [AUG. 

specific grayitj, and as there was no solid mass whatever to be felt, 
— only a thin-walled cyst, — it seemed more pradent to delay for a 
time any farther interference. 

She suffered severely for several da^s after the tapping from 
abdominal pain, vomiting, and vesical irritation. She was, however, 
able to be about again in ten days, and for nearly eight months she 
enjoyed excellent health, and no trace of the cyst could be detected. 
About the end of Februanr, however, it suddenly began to fill with 
great rapidity, she quickly lost flesh, and it was agreed to remove 
the tumour as soon as the oddema of the lower extremities should 
commence. 

This was accordingly done on the 26th of March. Professor 
Syme, Dr Dewar of Kirkcaldy, Dr Sidey, and Dr Keith were 
present. An incision about three inches in length was made, com- 
mencing midway between the umbilicus and pubis ; the peritoneum 
opened to half this extent, and a large non-adherent cyst tapped 
and drawn out. The cyst arose close from the uterus, the cuimp 
was placed round its lower portion, and from the absence of pedicle 
and great depth of the pelvis, there was a considerable drag upon 
the uterus, which was brought up close to the wound. In conse- 
quence of this there was a good deal of dragging pain in the back 
complained of for the first forty-eight hours, to relieve which small 
opiate enemas were given by the nurse when the pain got trouble- 
some ; otherwise no unpleasant symptom appeared, and she did not 
suffer nearly as much as she had done after the tapping. She was 
in the dininff-room to breakfast by the end of the third week, and 
returned to the country twenty-five days after the operation. 

This lady is the wife of one of the best known and most sue- 
cessftil Scotch provincial surgeons, — a man of unusual sagacity, 
but unfortunately long laid aside from active life by great suffering ; 
and his experience of ovarian tumours during a long and active 
practice of nearly forty years did not encourage him to recommend 
any other mode of treatment than the radical cure. And while 
he observed the slow but steady progress of the disease, and looked 
forward to the time when it would necessarily interfere with 
the life of his wife, he keenly watched the history and progress 
of ovariotomy in Great Britain, and so far back as ten years ago, 
having thought the matter out for himself, he venturea to assure 
her, that by the time her tumour should require interference, the 
operation of ovariotomy would be as common an operation, and 
more successftil in its results, than amputation of the leg. Till 
1868, however, the success of the operation in England had not 
been very encouraging, and in Scotland and Ireland the results had 
been invariably unsuccessftil. Its progress at that time seemed 
stationary, or rather it seemed to retrograde ; for the surgical heads 
of the profession would not give it a fair trial, while the majority 
denied it a place in legitimate surgery. The success which Mr 
Lane had met with, was quite unknown to the profession, while the 



1 864.] CASn OF OTASIOTOVT BT DB KBTTH. 158 

mode of operating adhered to by Mr Claj of Mancheater did not 
do much to recommend the operation ; for be continued to force 
aingle cysts through the large incision, learing the stomp of the 
pedicle to decompose in the abdominal 



cavity, and giving reiy 
quantities of opium as an essential part of the after-treat- 
ment But, in 1858, the operation was taken up in earnest by Mr 
Wells. In his hands it was much simplified, and he introauoed 
common sense into its after-treatment It became at once evident 
that a period of Drosress had begun, and it may be imagined how 
eagerly were watcnea the brilliant results that year after year have 
followed the operation in Mr WeUs' hands ; for there can. it seems 
to me, be not the shadow of a doubt that to Mr Wells belong the 
credit of reviving this operation in England, and of establishing 
it as one of the most justifiable and often most welcomed operations 
in surgery. 

The above case, though the simplest I had yet operated on, and 
the only one in which I had not met with extensive adhesion, is, 
however, a very important one, as showing the confidence with 
which tne operation of ovariotomy is being received by the pro- 
fession. In this family there were no fewer than four active and 
intelligent medical practitioners, who. when the question of ovari- 
otomy was brought near them in tne person or a near relativCi 
thought the whole matter out for themselves, and recommended the 
operation ; and they were all too good surgeons not to recognise the 
good surgical principle, that the less broken-down the general health 
of the patient the greater would be die probability ofsuccess. 

{To be continuecL) 



^art Seconlf. 



REVIEWS. 

JTie EssenJfialB of Materia Medica and ThetapeuHcs. By AlfbBD 
BARiKa Garkod, M.D., F.B.S., Professor of Materia Medica 
and Therapeutics at King's College, Iiondon, etc., etc Second 
Edition, revised and much enlarged. London: Walton and 
Maberly: 1864: pp. 891. 

The work, the title of which forms the heading of this article^ will 
be gladly welcomed both by the medical student and practitioner. 
A complete but concise book on Materia Medica and Therapeutics 
has been a real desideratum. Most of the text-books of this as of 
other subjects are much too long ; the writers seem to endeavour to 
lay before their readers not only what will be really useful, but a 

VOL. X.— NO. IT. u 



154 DR QABROD ON THE ESSENTIALS OF [aUO. 

mass of details often calculated to conftise^ if not to mislead. Dr 
Garrod has avoided this error, and has brought together in a small 
but remarkably neatly got up volume, the facts of Materia Medica 
with which it is really necessary to be acquainted. The work 
appears with peculiar appropriateness at the present time. The 
profession has not yet ^t thoroughlv acquainted with the New 
pharmacopoeia, and has, m fact, scarcely made up its mind as to its 
merits or defects. Numerous helps have indeed been published ; 
but, though useful when taken in connexion with large works, they 
are by themselves too small to serve the purpose of works of refer* 
ence. Dr Garrod's work is not only an explanation, and^ in some 
respects, a commentary on the New Irharmaoopoeia, but it is a com- 
plete treatise on Materia Medica. 

For the preparation of such a work Dr Garrod possessed peculiar 
qualifications. As a lecturer on Materia Medica, as an nospital 
physician, as a careful observer of disease, his attention has oeen 
for a long time directed in an especial manner to the action and 
uses of medicines ; while, as a member of the Pharmacopoeia Com- 
mittee, he has had the best opportunities for knowing the grounds 
on which alterations in the Materia Medica and in pharmaceutical 
processes have been made, and has had abundance of time to make 
up his mind as to whether these alterations have been judicious or 
the reverse. It has not, however, been Dr Garrod's object to enter 
upon the consideration of controversial points; the information 
regarding the therapeutical action of medicines is confined '^ to the 
facts really ascertamed as to the action of each drug, and the 
purposes for which it has been advantageously employed." 

The work commences with an introduction which treats of weights 
and measures, and of the different kinds of pharmaceutical prepara- 
tions ; though exten£ng to only ten pages it contains all the infor- 
mation on these subjects, which is really essential to the practitioner. 

The plan on which the Materia Medica is considered is the same 
as that followed by Pareira. Inorganic substances are first treated 
of, arranged under a scientific division ; then come drugs derived 
from the vegetable, finally, those from the animal kingdom ; an^ 
inconvenience attending this arrangement, when speedy reference is 
required, is obviated by a verv full and accurate index. In treating 
of the separate articles of the Materia Medica, Dr Garrod commences 
with a description of the crude drug ; this is followed by a state- 
ment of its properties, composition, and officinal preparations ; then 
comes an account of its physiological and therapeutical actions, and 
the doses in which it is to be employed ; finally, we have, where 
necessary, a descs^tion of the tests by which the article is to be 
recognised, and an account of the chief adulterations to which it is 
liable. Tnough much in the book is the same as is met with in the 
British Pharmacopoeia, and the officinal preparations are of course 
extracted from it, Dr Garrod follows that standard by no means 
slavishly ; he gives, indeed, every preparation contained in it, but 



1864.] MATERIA UEDICA AKD THEBAPEITTICS. 165 

he retains several old drugs which it has abandoned^ and admits 
several new ones which the national work has not recognised. 

The most interesting and most original portion of the work is 
that devoted to the actions and uses of medicines, and we are dad 
to see that Dr Garrod proposes to follow this volume with another, 
which shall embrace the whole subject of Therapeutics, and treat of 
it in a more exhaustive manner than was possiole within the com- 
paratively narrow limits of the work before us. At present, there- 
fore, we shall select almost at random a few of Eh: Uarrod's state- 
ments regarding particular medicines, rather to show how the 
subjects are treated of, than with a view to an^ formal criticism. 

Arnica, our readers are aware, has been admitted into the British 
Pharmacopoeia ; but considering that this drug has been principallj 
employed Dj the homoeopathists, the existing testimony in its favour 
is not of a strong character. Dr Garrod seems to distrust it alto- 
gether. Begarcung its therapeutical properties he says, — " Given 
internally, arnica acts as a stimulant and irritant : it has been sup- 
posed to influence the spinal cord ; its action upon the system has 
not, however, been satisfiictorily made out It is chiefly employed 
as an external application for the discussion of tumours, and for 
sprains and bruises. The author has leasons for questioning the 
virtues of arnica as a remedy in these cases." Our own experience 
is quite in accordance with Dr Garrod's; we have employed it 
occasionallv in cases of sprains and contusions, but have not noticed 
it to be followed by anjr better effects than mignt have been expected 
to follow any other spirituous application. 

In Lithium, Dr Garrod has a personal interest, the salts of that 
metal having been introduced by himself for the treatment of uric- 
acid gravel, and chronic gouty conditions. The advantage which 
lithia and its carbonate possess over the corresponding compounds 
of sodium and potassium is, that they possess great neutralizing pro- 
perties, and that the urate of lithia is much more soluble in water 
than any other known urate. Regarding the therapeutic actions of 
the salts of lithia, Dr Qtmrod says in the wcwk before us, — " From 
the small amount of lithia sufiicient to form a salt with uric acid, 
and the much greater solubility of the salt, it follows that unless 
other circumstances interfere with their aaministration, the lithia 
salts must be valuable remedies when it is desirable to keep uric 
acid in solution during its transit through the urinary organs, or 
prevent its deposition in the structures of the body. The carbonate 
of litliia acts as a diuretic, and in the same dose has a more powerful 
influence in rendering the urine alkaline than the corresponding 
salt of soda or potash. It may be given with great advantage in 
certain states ot the system in which urate of soda is liable to be 
deposited in the tissues, as in gout, etc. Dose. Of the carbonate, 
3 er. to 6 gr. The carbonate may be given in aerated water ; free 
dilution aids its diuretic action." 

To the preparations of Cerium, however, Dr Garrod does not seem 



156 DR QABROD ON THE ESSENTIALS OF [AUQ. 

to have devoted any special attention. About ten years ago. 
Professor Simpson recommended the oxalate and the nitrate in 
those classes ot cases where a combined tonic and sedative action 
was required. He found them useful in cases of irritable dys- 
pepsia, gastrodynia, and particularly in the vomiting of pregnancy* 
Otner observers have met with similar results, and although tne 
salts of cerium are not to be looked upon as specific, tbey are 
undoubtedly useful in many cases. Disappointment was therefore 
experienced in man^ quarters that cerium and its compounds had 
not been admitted into the British Pharmacopoeia, as some other 
substances had been admitted on — to say the most — no stronger 
grounds, while their admission might have given an impetus to their 
employment, and their real properties would therefore have been 
soon settled. Dr Garrod mentions cerium, indeed, but his notice of 
it is very brief. ^^ Some of the salts of cerium, a metal which exists 
in a few rare minerals, as cerite, have been maaeuse of in medicine. 
The oxide and the oxalate of cerium have been most frequently 
used, and occasionally the nitrate has been ^ven. The cerium 
salts have been chiefly emploved to allay vomiting, especially that 
which occurs in pregnancy, also in the vomiting of pnthisis ; and 
in some cases of epilepsy accompanied with gastric disturbance. 
The dose of the preparations of cenum may be nom 3 to 5 grs." 

We shall give one more quotation from Dr GaiTod's work, 
selecting the passage treating of^the therapeutical action of digitalis, 
both as affording a better specimen of Dr Garrod's style than the 
preceding short extracts have enabled us to do, and because con-* 
siderable difference of opinion prevails in the present day regarding 
the sedative action of the drug. The opinion long entertained was 
that digitalis acts as a direct and powerftil sedative of the heart's 
action ; recently, however, some have maintained that it stimulates 
the muscular substance of the hearty and augments the contractilitnp' of 
the capillaries, and that when it kills, it does so, not by producing 
paralysis, but by giving rise to contraction and spasm of that organ!^ 
Dr Garrod, it wiu be seen, adheres to the old view, although it 
will be noticed that he alludes to a difference in its action on the 
capillaries when compared with that of other sedatives. 

" When taken internally, the most marked effect produced by the drug is 
the weakening of the heart's power, accompanied by a diminished rate of the 
pulse ; some observers assert, that the heart's action is primarily auickened. 
If the dose be increased, or continued after a certain amount of caraiac weak- 
ness has been induced, symptoms of an alarming character may arise, such as 
nausea, vomiting, faintness. and syncope ! this is especially apt to occur when 
the patient attempts to make any exertion, or even to sit or stand up ; in fact, 
patients under the full influence of the drug, which is sometimes purposely 
induced, are only in safety when in a horizontal position. Although dijgitaha 
acts BO powerfufly ujjon the heart, yet its influence over the capillary circula- 
tion, when in a morbid condition, is by no means so powerfully exercised as in 
the case of antimonial and mercurial preparations. Digitalis oAen produces 
copious diuresis, more especially when the deficiency of the urinary secretion 

» See Fuller on Diseases of the Chest," p. 592. 



1M4.] MATBftU MSOICA AKB THKRAPEUTICB. 157 

depend* on cardiac diteaiM ; it also occaaionaOj indocea ileep, or acta aa a 
aeoatiTe and soporific, bat onlj when the reatleaeneas ta due to an over-eidled 
state of the heart. Digitalis u administered as a cardiac sedatire in almost all 
cases where there is eialted action, whether sympathetic in nature, or depend- 
ing on organic disease of that organ, or of the mat Tessels, as In hypertrophr, 
^nriam, or valTalar disease, etc ; it ahoolo, howtrer, alwajrs ne borne m 
mindf that increased action of the heart is not always an indication of bcreased 
strength. Digitalis may be given also in hsemorrhages of an actire charaeteri 
and as a diuretic in dropsies depending on the above-named cardiac diseases, 
and sometimes in other forms. 8ome practitioners hare proposed the nae ai 
digitidis in inflammatory affections, bat in these cases its efficacy has not been 
wdl established. It has also been employed in phthisis, bat witlioat permanent 
benefit; for althongh it often in these cases diminishes the rapidity of the 
pulse, it exerts no influence on the progress of the tubercular disease. l)igitalia 
IS generally asserted to be a drug the action of which is cumulative in character : 
the explanation of this pecoliaritv appears to the author to be as follows, tib., 
that considerable weakening of the neart*s action may occur without any rery 
OTident symptom being produced ; but if this is increased aboTe a certain point, 
so as to interfere with the efllciency of the circulation, then all the symptoms 
are rapidly and dangerously manifested.** 

For fuller detaila, bowever, regarding the tlierai>eatic action of 
this and many other drags, we shall looc forward with intereat to 
tbejpromiaed volome. 

We most not omit to notice a verj naefol feature in Dr Garrod's 
work, in the shape of a poBological table, in which may be seen at a 
glance the appropriate dose of all the articles of the Materia Medica. 

In taking leave of Dr Garrod for the present, we have to repeat 
our recommendation of ^' the Essentials of Materia Medica and 
Therapeutics^' as an admirable work in itself, and as an indis- 
pensable companion for the student or practitioner to the British 
Phannacoposia, 



TranBoctians qf the Odxmiological Society^ 1861-1863. Vol. IIL 
Published by the Society. 

The Teeth in Health and Dieease. By Robert Thomas Hulme, 
F.L.S., etc H. Bailli^: London: 1864. 

Enobmous as is the progress in every department of medicine and 
surgery within the last half century, in none has the improvement 
been more marked than in the diagnosis and treatment of the lesions 
of the teeth. The itinerant charlatan, with his harlequin and 
chariot, his mullets, forceps, and keys, and the infallible specific for 
toothache, has been superseded by a thoroughly educated medical 
gentleman, who must be anatomist, chemist, physiologist, and 
mechanician, if he means to rise above mediocrity. And this pro- 
^resB is one which has this element both of stability and growth 
m it, that it has begun at the right end. From scientific experi- 
ments and researches, anatomical and microscopic, it has gone on 
to improvements in praotice; from the labours of Nasmyth and 



158 TRANSACTIONS OF THE ODONTOLOGICAL SOCIETY, ETC. [AUG. 

Groodsir, Tomes and De Morgan, to improvements in manipulative 
dexteri^ and mechanical appliances. 

The Transactions of the Odontological Society for 1861-63 con- 
tain several papers of very hi^h character. 

Among these is a remarkaUe and original prize essay, by Mr W. 
K Bridgeman, on the Pathology of Dental Caries, which^ based on 
researches of Davy, Faraday, and others, and extended into much 
ingenious experiment and reasoning, tends to the belief that the 
^' progressive decomposition of the enamel and dentine are due to 
local electro-voltaic action." From the remarkable concentration 
of the writer's style, and from the arrangement of the paper in a 
serious of propositions, any attempt at abridgment is futile ; but as 
a most suggestive and danng inroad into a comparatively untrodden 
field, it will repay a most careful perusal. 

The papers oy Mr Coleman on " Dental Caries ;" by Mr Spence 
Bate on " The Treatment of Inflamed Dental Pulp ;" by Mr 
Bridgeman on " Caries and its Treatment," are important contribu- 
tions to dental pathology and therapeutics ; while the two papers by 
Mr Truman " On the Necessity of Plasticity in Mechanical Den- 
tistry," and " On the Manufacture of Mineral Teeth," indicate the 
^at progress which has been made, and is still making in mechan- 
ical dentistry. 

Luxuriously printed, profuseljr and beautifully illustrated, these 
transactions speak well for the vigour of the society which publishes 
them. 

Mr Hulme's book is a plain, short, and pleasantly written account 
of the anatomy and diseases of the teeth. The advice concerning 
the mana^ment, both of dentition and of the perfectly finished 
dental arch, show that it is intended more for the public than the 
professional reader. Its perfect freedom from all professional tech- 
nicalities renders it fit for the perusal of the public, while its sensible 
directions as regards cleanliness, care, and an early visit to the dentist, 
render it a much more useful and safe work to place in nonprofes- 
sional hands than many otiiers which aim at making every man his 
own physician. 



Phthisis wnd Ae Stethoscope ; or the Physical Signs of Consumption. 
By Richard Payne Cotton, M.D., Physician to the Hospital 
for Consumption and Diseases of the Chest, Brompton. liiird 
Edition. London: Churchill: 1864. Pp. 104. 

Some years ago,* on the publication of the second edition of this 
little work, we strongly recommended it to our readers as containing 
a brief, but accurate and thoroughly practical account of the signs 
of phthisis. The present edition has been carefrilly revised, more 

> See this Journal for December 1859. 



1864.] DR COTTON ON PHTHISIS AND THE STETHOSCOPE. 159 

than twen^ P^^S^ ^^^^ ^^^" added to it, and it will be found even 
more valuable Uian its predecessor. 

The principal changes in the present edition consist in the addition 
of a chapter on '^ the classification and nomenclature of the physical 
signs ; " and of another which treats of the ^^ physical signs indi- 
cative of arrest or improvement of the polmonary disease in the 
several stages of phthisis.'' Of the former of these we have nothing 
particular to remark ; while not entering into unnecessary refine* 
ments, it explains the more common sounds, and gives a vocabula^ 
of the physical signs which are useful in the diagnosis of the disease. 
The chapter whicn treats of the physical signs indicative of arrest 
or improvement in the pulmonary disease contains interesting 
matter, and will fill up a blank which the readers of larger ana 
more pretentious treatises must have often experienced. It is of 
great consequence to bear in mind, that in order to arrive at a 
rational prognosis in a case of phthisis, a single examination is 
seldom sufiicient; a knowledge of the existing condition of the 
lungs is not enough, and the physician must satisiy himself, bv 
frequent examination, whether the disease be advancing, retrograd- 
ing, or remaining stationary. In connexion with this point, the 
beginner would do well to bear in mind the following statement of 
Dr Cotton, as showing that the mere presence of abnormal physical 
Sims is not sufficient to justify the inference of advancing disease : — 
"With the exception of the improved respiratory murmurs, and 
the diminution or absence of secretion sounds, other morbid condi- 
tions may possibly remain unchanged, although, perhaps, the pul- 
monary mischief may be arrested. The dulness mav possibly still 
continue, owing either to thickening or adhesion of ttie pleura^ 
which is generally a permanent condition, or else to quiescent 
tubercle, or secondary pneumonic condensation — ^which may be 
equally permanent. For like reasons, the same may be said of 
morbid alterations in the form and movement of the chest walls, 
and of vocal and tussive resonance. The nearer the approach to 
healthy condition in these respects, of course, the better ; but it 
should be borne in mind that their continued deviation firom*the 
healthy standard is no proof that the patient is not progressing 
satisfEbctorily, or that his disease is not arrested." 



On Diabetes and its Suecew/ul TreatmenL Bv John M. Campxin. 
M.D. Third Edition. Eevised, with Additional Notes ana 
Observations, by James Gret Gloveb, M.D. London : Church- 
hiU: 1864. 

A PAKTICULAR interest attaches to the work of Dr Camplin as 
having been written bv a physician who was suffering from the 
disease which he described, and who, by careful management, was 



160 DR CAHPUN ON DIABETES. [AUG. 

able in a great degree to overcome it, so as to be able to enjoy a 
great degree of comfort, and to fulfil the duties of a laborious pro- 
^ssion without any very great restrictions as to diet. Dr Camplin 
died somewhat suadenly while engaged in preparing a third edition 
of his book, and the task of following out his intentions devolved 
upon Dr Glover. The moral both of Dr Camplin's and of Dr 
GHover's statements is that, while in most cases of diabetes much 
may be done to promote the comfort and to {)rolong the life of the 
sufferer, no remedy is known possessing specific power in the cure 
of this disease. Still the subject is a hopeful one, and we may 
quote from Dr Glover's preface the following sensible observations : 
— ^^ The present position of the subject of diabetes is fnll of interest 
and promise. .6ur advancing knowledge tends wonderftilly to 
fasten upon certain parts of the body the origination of the abnormal 

Sroduction of sugar in the system which chiefly characterizes the 
isease. Though no specific remedy has been discovered for it, 
great progress has been made in defining the treatment by which it 
IS most effectually controlled. And, by the way, let it be said, that 
this is a good illustration of the progress of therapeutics in general. 
Our control over disease seems to be advanced not by the discovery 
of single remedies, but by discovering the importance of, and pre- 
scribing regard to, a number of physiological considerations, and 
the judicious use of helpful, but not specific, medicines. At the 
same time, it may be remarked, that the case of diabetes is one so 
peculiarly chemical in its character, that it is not unreasonable to 
hope for the discovery of a chemical remedy for it. Meantime it is 
satisfactory to be able greatly to command the disease, to mitigate 
the distress which it occasions, and to enable a great number of 
diabetic patients to follow their callings with comfort and efficiencyi 
even to an advanced age." 

We have only to state in conclusion, that Dr Camplin's book is 
well worth V of the attention of medical men, as being ot a thoroughly 
practical character, almost every statement in it having been sub- 
mitted to the test of an intelligent experience. 



An Elementary Text-Book of the Microscope : including a Deacrwtion 
of the Methods of Prepariruf and Mounting Objects^ etc. ny J. 
W. Griffith, M.D., F.LiS. With Twelve Coloured Plates. 
London : Van Voorst : 1864. 

The microscope is no longer exclusively reserved for the man of 
science. It is now in the hands of every one who cultivates, no 
matter how superficially, any branch of natural history, and its em-* 
ployment has opened up new fields of instruction and enjoyment 
Under these circumstances, it is very important that beginners 
should have a text-book which, while strictly accurate, should be 



1864.] DR GRIFFITH ON THE MICROBCOPE. 161 

as free as possible from technicalities^ and should not presuppose 
any pieyioos knowledge of the subject. Such a text-lK>ok it has 
been Dr Griffith's obiect to fiupplj, and the result has been in the 
highest decree satisfactory. Ihe descriptions are clear and intel- 
ligible, while they have been supplemented in a most important 
manner by the introduction of twelve beautiftilly coloured plates, 
containing between four and five hundred figures. The figures are 
thorough^' true to nature, are remarkably well executed, and refer- 
ence to tnem will be of the greatest possible assistance to the 
beginner. On the whole, we consider this as undoubtedly the best 
text-book of the microscope for the general student. 



part ^ivn. 

PERISCOPE. 
PRACTICE OP MEDICINE. 

ON THE SLIGHT FORM OF SCABLATINA AMD SCARLATINAL DROPSY. BY DR ROGER. 

There have been lately (in the HdpUal dea Enfimts Makuka) a great many cases 
of what Dr Roger calls scarlatinettes. They were cases of scarlatma extremely 
slight, or so lugacions, that the characters of scarlatina passed unobservea. 
Nevertheless, the disease, of which the external manifestations were so slight, 
was still present, and if the patients, apparently in good health, and recovered 
from a seemingly trivial eruption were exposed to cold, haemataria or dropsy, 
sometimes fatal, made their appearance. In one case, an impression of fear 
appeared to play the part of exposure to cold, and producea anasarca in a 
little ^1 four jeara old, who, ner parents declared, had escaped from the 
scarlatina her sister had had, bat who really had had the disease so slightly, 
that even maternal solicitude had not detected its existence. At other times 
there are anomalous eruptions which have features in common both with 
measles and scarlatina, without, however, belonging to either ; such are the 
eruptions which have received from different modem authors the names of 
erythema scarlatiniforme, roseola sestivalis, roseola miliaris, rosalia, rubeoloid, 
riitheln, and rash. According to M. Almeras, who has written a very interest- 
ing work on the scarlatiniform exanthemata confounded with scarlatina, it is 
at first impossible to give a certain diagnosis. It is only at the second stage 
that the disease assumes the following characters, — eruption of a rosy colour, 
diffuse, punctuated ; slight angina, but without marked redness of the throat 
or tumefaction of the tonsils, nor cheesy concretions ; tongue not characterized 
by the intense redness and the prominent papilbs characteristic of scarlatina; 
no grave general symptoms ; nothing remarkable with regard to the pulse. At 
the third stage desquamation is absent, or when it exists it occurs in a branny 
form, not as large scales ; the urine is normal ; there is no anasarca. But we 
repeat, if there are pretty well marked differences between scarlatina and the 
scarlatiniform exantnemata, the points of resemblance between them are numer- 
ous, and, as in times of epidemic it is very difficult to distinguish them, it is 
prudeftt when any doubt exists to act as if the disease were scarlatina, and to 
make children keep to their bedroom for at least a fortnight if they have pre- 
sented any trace of an equivocal eruption. Accordingly, if there are cases of 
Bcarhitina well characterized from the first, and where there is no room for 
doubt, there are others much less marked, and which may be confounded with 
exanthemata of quite a different nature. Still these little characterized forms 
VOL. X.— NO. II. X 



162 PERISCOPE, [AUG. 

merit serious attention, because they are as much if not more likely than the 
others of beins followed hj one of the most formidable accidents of scarlatina, 
—dropsy, with albuminuria. \ 

It is from the fifth to the tenth or twelfth day of the eruption that the 
albuminuria supervenes. If the albumen is very abundant in the urine, dropsy 
follows. According to Roger, dropsy occurs about once in seven cases, and it 
usually appears from the tenth to the twentieth day. But as experience shows 
that in the immense majority of cases it is exposure to cold which leads to 
anasarca, this practical deduction follows that every child affected with scarlatina 
should keep its bed a fortnight, and its room at least three weeks. After three 
weeks anasarca is not to be dreaded, or at least its occurrence is improbable. 
Dr Roger, in fact, does not admit that anasarca may occur during the whole period 
of desquamation ; he thinks that the patients who have been attacked witn it at 
a later period than that indicated above, had a chronic Bright^s disease con- 
nected with a peristent scarlatinal albuminuria, or an acute Bright's disease 
independent of scarlatina, which is not very rare in children. 

Among the precursors of anasarca, vomiting should be noted. If between 
the tenth and twentieth days of scarlatina a child becomes a little feverish and 
vomits, we may apprehend anasarca ; the latter generally appears the next or the 
following day, and is characterized by a deceitful appearance of stoutness. In 
general the urine assumes a red colour, and presents corpuscles analogous to 
the grounds of coffee, which enable us to detect the presence of blood without 
having recourse to the microscope. In half the cases the dropsy remains ex- 
ternal, in the other half you have internal effusions. So long as there is only 
abdominal dropsy, matters are not very serious, but it is different when serum 
accumulates in the pleura, for as the effusion is generally double, and the 
pulmonary substance is infiltrated, extreme embarrassment of breathing is the 
result. To this dropsy, oedema of the glottis is sometimes added, for which it 
IS necessary to perform tracheotomy. But of all effusions the most dangerous 
is the encephalic, which may assume the comatose, the paralytic, or the convul- 
sive form. With regard to the convulsions which occur under these circum- 
stances, Dr Roger says, that though the prognosis is venr grave, the patients 
who manifest them recover in the proportion of one-third. 

The preventive treatment of scarlatinal dropsy consists, as has been said, in 
keeping the child carefully from exposure to cold. The curative treatment 
wiU vary according to the form of dropsy. If it is febrile, active, if the tissues 
affected be of a rosy colour, if the skin be hot, sanguineous emissions are indicated. 
This is still more the case if there is oedema of the lungs. Bleeding then gives 
manifest relief; bleeding from the arm is preferable to leeches or cupping, 
which may produce erythema or erysipelas ; it has this disadvantage that it is 
pften difficult of performance, but if^ possible recourse should be had to it ; 
blood should be arawn to from three to six ounces ; this may be repeated if 
necessary, but in general one bleeding is sufficient. We must then endeavoitf 
to find means of exit for the serum, although we must respect the kidneys and 
treat the intestines with reserve. It is on the skin that we must act by means 
of stimulants and diuretics. Dr Roger prefers dry to moist frictions. Flannel 
impregnated with the vapour.of benzoin or of juniper may be employed for 
this purpose. At the end of two or three days recourse may be had to vapour 
baths aoministered ever^r day or every two days. At the same time, acetate of 
ammonia may be administered internally, in the dose of half a drachm to a 
drachm in two or three cups of infusion of elder. This treatment is suitable 
for the acute cases. In the chronic form, unless in the presence of complica- 
tions which require bleeding, we trust to diuretics, drastic purgatives, and 
repeated blistering over the chest. If there are cerebral symptoms we may 
apply leeches to the mastoid processed, and blisters to the thi^ or nape of 
the neck ; then we administer hydragogues, and give nitre in doses of from 
half a drachm to two drachms in the twenty-four nours. In simple cases Dr 
Roger prescribes, along with vapour or sulpnurous baths, dry cupping over the 
loins, mtric acid lemonade, and a mixture containing from eight to fifteen grains 
of tannin.— Journal de Midedne et de ChirurgU pratiques. 



1864.] PRACTICE OF MEDICINE. 163 

ON THE INFLUENCE OF PLEURISY IN THE DBTELOPMEMT OF PHTHIB18. 
BT DR BEAU. 

bf the Hospital of La Charity is a patient whose case, thoujgh apparently of 
little importance, has given Dr Beau the opportunity of pointing out the influ- 
ence which pleurisy seems to exert on the development of phthisis. Between 
these diseases there is a very close connexion ; often j^leurisy merely supervenes 
upon phthisis ; hut it is not uncommon to see a pleurisy occur in a subject who, 
tul then, has presented no rational sign of phthisis, and to see it followed by the 
development of that disease. This was the opinion of Broussais, who attri- 
buted to inflammation the formation of tubercles, and Dr Beau has met with 
many fiicts which have led him to the same conclusion. Thus, in the case of 
the patient in question nothing indicated a year ago that he was tubercular. 
This winter he took a pleurisy, perhaps two ; when admitted into La Chants 
there was still a little effusion into the left side, which remained persistent, and 
was accompanied with a little febrile excitement towards evening. A bUster 
removed the effusion, but did not lead to the disappearance of the fever ; the 
patient was then carefully auscultated, and the presence of tubercle was recog- 
nised in the left inferior scapular re^on. Cases of the kind are not uncommon. 
Dr Beau had for his house phvsician a young man who contracted pleurisy ; 
two ^ears later he died tubercular. At this very time he has under treatment 
a patient whom two years ago he treated for pleurisy, and who is now tuber- 
cular. Many other examples could be quoted of tubercle supervening upon 
pleurisy. Is this any reason for treating these patients according to the system 
of Broussais ? By no means ; a very spare diet is bad because it debilitates, 
and an enfeebled state of the organism opens the door to all the diseases which 
afflict humanity. — Jowmal de Midecme ei de Chirurgie pratiques. 

ON TUOEACENTEBIg IN PLEURITIC EFFUSION. BY DR BEHIEE. 

A LONG discussion on thoracentesis has occupied the Medical Society of the 
hospitals of Paris ; and as the debates were not free from a certain degree of 
confusion, Dr Behier has made a critical review of them, the conclusions of which 
may be thus briefly stated. 

Thoracentesis is indicated and ought to be performed : In all cases where the 
effusion is in large quantity, and does not diminish rapidly under the ordinary 
means, and still more if it goes on increasing ; in all cases where the patient 
appears too delicate, too w^kk to bear up against the long process of resorp- 
tion of an effusion which occupies completely or nearly completely one side of 
the chest ; in all cases where, although the effusion is not very copious, we find 
the opposite lung impeded in the performance of its function, as by bronchitis, a 
certam degree of oedema, etc. ; in all cases where we believe we have to do with 
a patient predisposed to pulmonary phthisis, whether we are unable to make 
out its existence, or whetner we have the proof of it in the side occupied by the 
effusion, or in the other lung. The last case we willingly allow \& by no means 
fiivourable. 

Before practising the operation, we wait, if possible, until the inflammatory 
phenomena have abated ; it is generally between the ninth and the eleventn 
days that we expect to see this iA>atement. At the same time, it must be borne 
in mind, that inflammatory symptoms may be altogether absent, or at least very 
little marked in a large nmnber of cases of copious effusions, and that it is pre- 
cisely in these cases that sudden deaths are most frequent, as they are also those 
which recover best after thoracentesis. To refuse the operation in such cir- 
cumstances on account of the slight apparent ^vity of the disease, and because 
we observe neither violent dyspnoea nor immment asphyxia, would be, in our 
opinion, a grave fault on the part of the physician. These cases frequently 
occur in persons of little vital energy ; their very passiveness is often an obstacle 
to their cure by ordinary means. Little capable of undergoing the process of 
absorption^ we ought to aid such patients in the process, and thoracentesis 
affords this indispensable assistance.— Jotima/ de Midecme et de CIdrurgie 
pratiques. 



164 PERISCOPE. [auo. 

ON THE EMPLOYMENT OF APIOL IN AMENORRHCEA AND DYSMENORRnCEA. 
BY DR CORLIEU. 




tions suggested by my own practice. I have now employed apiol for eight 
years, sometimes successfully, sometimes not. I shall endeavour to point out 
the cases where it may be expected to prove useful. 

A. In all cases where the menstrual disorder dei>ends upon the derangement 
of a vital element, where there is plethora or anssmia, apiol should not be used, 
for, being a nervous tonic, it will only aggravate the condition of the patient. 
But if the condition of chlorosis be removed, apiol may be prescribed with a 
ffood prospect of success. The following case will illustrate this : — A kdy^ 
wirty-eight years of age, of a lymphatic and nervous temperament, had suffered 
for three months from amenorrhoea, complicated with extreme chlorosis. Dr 
Gkdligo at first ordered apiol, but without success. At a later period he com- 
bined it with chidybeates, which had previously done no good. The combined 
use of iron and apiol effected a cure. Dr Marrote relates the following case :— 
Miss C, eighteen years old, was of a lymphatic temperament. In childhood 
she had had measles, hooping-cough, and modified smallpox. Her skin was of 
a dead white, her face somewlmt swelled ; the gums were swelled and discoloured ; 
she had very little appetite, and often vomited her food. She menstruated 
first when fourteen years old ; for several months the discharge was white, 
afterwards it became of a reddish colour, but was accompanied by such severe 
uterine pains, that she was obliged to keep her bed. As she was to menstruate 
on the l8th of October, I ordered her two capsules of apiol on the 15th, two on 
the 16th, and two on the 17th. On the 18th, the menses appeared, though still 
in small quantity, but unaccompanied by colics or uterine pains ; they only 
lasted two days, and the blood was still very pale. On the Slst, I ordered a 
chalybeate which was continued till the 18th of November, when she resumed 
the apiol for three dftys. The menstruation was unaccompanied by nains ; it 
continued three days, and the dUcharge was more coloured and more abundant. 

B. When the menstrual disorder depends upon a diathetic condition (dartres, 
scrofiila, etc.), we must, by means of a specific treatment, such as bitters, cod 
liver oil, preparations of iodine, sulphur, or arsenic, attack the principal malady. 
Apiol is of no use at first in these cases ; but when the cure of the morbid 
diathesis has been effected, it may be employed with advantage in stimulating 
the torpid menstrual function. 

C. tfut it is chiefly in disorders which are under the influence of the 
nervous system that apiol is a heroic remedy, leaving far behind it all the 
emmenaeogues hitherto employed. As a neurotonic it supplies to the nervous 
system the energy it has lost. Change of life, of habits, or of climate, often 
determine amenorrhcea. This is a fact which must not be forgotten, and 
which is well known to the physicians of boarding-schools and religious houses. 
This menstrual suppression is transitory ; it lasts some months, and sometimes 
only gives rise to slight nervous disorders, or a slight oddity of character. In 
these cases, two, four, or at most six capsules of apiol will restore the menstrual 
flux. The following case was observed by Dr Marrote : — 

Miss L. J., seventeen years of age, bom in London, arrived for the first time 
in Paris in October 1861. She was a tall, handsome girl, of a good constitu- 
tion and plethoric temperament ; she had never had any serious illness. She 
menstruated for the first time at thirteen, but was very irregular up to fifteen. 
Although she never suffered from colics, or lumbar or inguinal pains, her 
periods were often delayed for a fortnight or three weeks ; the blooa, contain- 
ing fibrin, was pretty abundant. From fifteen to seventeen years, menstruation 
was quite regular. She then came to Paris to complete her education. From 
the date of her arrival until the month of March of the following year, her 
menstruation was completely absent. Nevertheless, no change had been 



1864.] PRACTICE OP MEDICINE. 165 

observed in her eenend health, thongh I was informed that at times she became 
daller, more m&ncholy, and more irritable than usual, and that this state 
continued for a short time. Taking this 'as an indication, I administered apiol 
in the dose of one capsule night and morning in a spoonful of water, beginnlnff 
on the 11th of March, which seemed to be indicated as a menstrual period. 
She thus took six capsules in three dajs. On the 14th of March, the menses 
appeared without pam, and lasted four days. The lady of the establishment, 
accustorned to see apiol almost always succeed under these circumstances, did not 
repeat it the followmg month. On the 14th of April, the menses returned, and 
lasted four days. On the 17th of May, the 16th of June, and the 2 1 st July, the 
same occurrea. Miss L. J. returned to her family in London in perfect health 
and quite regular. 

The sudden application of cold during a menstrual period may suppress the 
discharge abruptly, and give rise to amenorrhoea, which may last for aii indefinite 
time. In the month of January 1861, 1 saw a young lady, seventeen years of age, 
who had menstrated for two years, but in whom, in consequence of a chill during 
menstruation, the flow was suppressed. The belly became considerably enlarged ; 
there was, in fact, an ascites, which could only be explained by the amenorrhoea. 
There was no albumen in the urine. I employed, without success, purgatives, 
Budorifics, chalybeates, and the ordinary emmenagORues. There was consider- 
able pain at wnat should have been the menstrual periods. This state con- 
tinuea until the end of April. In May, capsules of apiol given night and 
morning restored the discharge, though at first it was piue and serous. Iron 
was continued, and from that time the abdomen diminished in size. The cure 
was complete. 

It would be easy to bring forward more cases, but the above may suffice. 
The point I wish to establish is, that apiol is the best emmenagogue with 
which we are ac(|uainted in all cases wnere amenorrhoea or dysmenorrhoea 
faAve their origin in a disturbance of the nervous element. The principal con- 
dition for success in the use of apiol is in the choice of the proper moment for 
its administration. In almost all cases of amenorrhoea or dysmenorrhoea 
which depend upon an organic cause, the use of apiol is contra- indicated. This 
IB not the place to lay down the differential diagnosis of these conditions. If 
apiol has succeeded in some cases of plethora, it has been because the plethora 
was not very considerable. **In order," says Dr Marrote, *4hat apiol may 
succeed, it is an essential condition that the pain which accompanies menstrua- 
tion depend upon dysraenorrhoea, properly so called, that is, on the vaso-motor 
innervation of the womb. It has never succeeded in calming nervous pains, 
dull or acute, which were seated in branches of the lumbo-sacral nerves, and 
especially in the uterus, pains which appear or become exaggerated at the 
menstrual period, and may at first sight simulate d^smenorrhoea proper." 
Another condition for success in the use of apiol consists in choosing a time 
for its administration corresponding to a menstrual period. If the woman has 
not properly calculated the period, we may be enabled to discover it by no- 
ticing the sympathetic denmgements which occur under these circumstances. — 
Oagette dee Hdpkaiuao, 

ON THE TBEATMEMT OF PRURIGO. BY DR DUCHESME-DUPARC. 

Prurigo is not a disease which directly compromises the existence, but its 
obstinacy, its tendency to relapse, and the insupportable annoyance which it 
occasions, render it one which often causes much trouble and anxiety to the 
practitioner. Prurigo especially affects the nervous and the sufferm^. It 
has been supposed to be contagions, but this is certainly not the case ; it may 
be complicated with itch, but when simple, no acarus or any other animalcule 
18 present. ^ What distinguishes the two diseases farther is, that the anatomical 
character of prurigo is the papule ; of itch, the vesicle. Sometimes, no doubt, 
the diagnosis may be different. Thus, in chronic prurigo, some papules may 
present at their summit a small vesicle, and on the other hand, the vesicles of 
the itch may rest upon a papuliform induration ; but even here the doubt 



166 PERISCOPE. [Aua. 

should not be frequent, and should not last long, both because such cases are 
rare, and besides the papules of prurigo occupy the back of the limbs and the 
posterior surface of the trunk, just tne contrary of what is noticed in itch. 
The pruritus again affords light to the practitioner who is in doubt. This is 
the essential symptom of prurigo, and is much more marked and persistent 
than that which is met with in itch. Besides, the small lamellated crusts which 
follow the vesicles of scabies, could not be confounded with the black concre- 
tions formed in prurigo by drops of dried-up blood. The violent itching of 
prurigo may- be simulated around the anus by ascarides in the rectum, by 
h»morrhoi&, by slight inflammation of the rectum ; and, in the case of the 
genital organs, by pediculi pubis, or eczema of the scrotum or vulva. 

In a practical pomt of view there are only three forms of prurigo — ^the recent, 
the chronic, and that which was called by Alibert the latent, where papules 
cannot be seen with the naked eye. At present we only speak of the treat- 
ment of this disease. 

If prurigo is recent, the antiphlogistic treatment affords the best results. If 
the subject is young, sanguine, and plethoric, and if the eruption occupies large 
surfaces, Dr Duchesne-Duparc commences by bleedine at tne arm, or applying 
leeches to the anus ; he then prescribes a milk and vegetable diet, cooling 
drinks, especially lemonade, prepared with nitric or sulphuric acid, and sweet- 
ened with syrup. He lays mucn stress upon bran baths, prepared by boiling 
four pounds of bran for half an hour in a suflSciency of water, and mixing it with 
the water of the bath. Frequent lotions are made from time to time upon the 
affected parts with decoction of lettuce, dulcamara, or poppy ; or the lotions 
are replaced by prolonged inunctions made with oil of nyo8c;^amus, opiate 
cerate, or the following preparation : — chloroform 75 grains, dycerine 300 grains. 
This treatment, combmed with mild purgatives, often leads to a sudden and 
complete cure. 

But if the prurigo be, as is usuall^r the case, of old standing, we must trust 
chiefly to external agents, thoush still insisting upon a suitable regimen and 
the use of acid drinks. The alkalies here form excellent topical applications ; 
the salts of potash and soda, in sufficiently diluted solutions, both favour the 
resolution of the papules and calm the itching. With the same object we may 
have recourse to simple or aromatic fumigations, vapour baths, sometimes even 
to corrosive sublimate. But the topical application to which Dr Duchesne- 
Duparc gives the preference is tar, in suspension or incorporated with lard and 
united with opium. Lotions and baths of tar- water should be frequently 
renewed. The following formula gives excellent results : — tar 60 grains, gummy 
extract of opium 15 ^ins, lard 1 ounce. In the case of baths and lotions it 
is well to add a gelatmous substance (such as 2 pounds of glue to 200 quarts 
of water), because the papillse parts are the most sensitive of the skin. Dr 
Duchesne-Duparc has found that sulphurous preparations are onl^ moderately 
useful in prungo. They only do good when it is complicated with pityriasis 
or psoriasis. The most useful of the mineral waters are those which are 
alkaline, and contain a thick vegetable principle, such as the waters of Neris. 

In prurigo pudendi, and in prurigo podicis, we must often have recourse to 
the application of prussic acia^ sulphate or muriate of morphia, chloroform, 
etc. Tn some patients benefit is derived by the occasional use of astringents 
and antispasmodics ; in others, slight and altogether superficial cauterizations 
do good. Nevertheless, though topical applications are very important, the 
necessity for internal remedies must not be overlooked, especially when the 
disease is of old standing. It is here that aconite is ver^ useful. Many years 
ago, M. Cazenave derived great benefit from the use of this substance in papular 
cutaneous affections, and. especially in prurigo. Considering prurigo as a neu- 
ralgia of the papillae of the skin, having as an accessory character the appear- 
ance of papules, M. Cazenave had recourse to the simultaneous employment of 
alkaline baths, and the use of the following pills :— alcoholic extract of aconite, 
extract of taraxacum, of each 15 grains. This to be divided into 40 pills, of 
which the patient took one or two night and morning. Dr Duchesne-Duparc 



1864.] PRACTICE OF MEDICINE. 167 

has made use of similar pills, bat generally prefers the tincture to the extract 
of aconite ; where the case is very obstinate the use of the arseniate of iron 
and emollient baths are often useful. The prolonged use of the bath is especially 
important. Dr Duchesne-Duparc often directs them to be of two or three 
hours* duration, and to be repeated daily. If, while the patients are under- 
going them, friction of the afllected parts of the skin, or, still better, an intelli- 
gent shampooing, be practised, a ver^ beneficial modification of the skin will 
be brought about.-~*/otima^ de MideAne et de Ckinirgie praUquei, 

TREATMENT OP ITCH AT THE HOSPITAL ST LOUIS. 

Dr Hardy's treatment consists in having the patient rubbed for half an hour 
with black soap over the whole body except the head, and the friction is con- 
tinued by the patient in a tepid bath of an nour's duration. On coming out of 
the bath, a rapid and general friction is made with the following parasiticide 
pommade : — ^hog's lard z ounces and 60 grains, sulphur 300 grains, sub- carbonate 
of potash and water, of each 120 grains. After the friction, the patient dresses 
without rubbing off the ointment, the contact of which with the skin is 
necessary for some hours, in order to finish the destruction of the acari, and 
to reach those which may have remained in the clothes. 

fVom 1852 to 1862, 37,429 persons have been submitted to this treatment. 
Of this number 535 have required to be treated a second time, and the success 
has thus been 69 cases out of 70 persons treated. — GaeeUe dea HdpUauz, 



MEDICAL JURISPRUDENCE. 

POISONING FROM CAUTERIZATION WITH THE ACID NITBATE OF MERCURY. 

BY DR YIDAL. 

Cauterizations witli the acid nitrate of mercury are made daily and without 
any particular precautions. We are apt to forget that this substance not only 
acts locally as a caustic, like sulphuric acid, \ ienna paste, etc., but that, like 
arsenical pastes, it is liable to be absorbed, and that, as the result of a too exten- 
sive cauterization, mercurial poisoning may occur. Facts of this kind are too 
important to be passed over m silence. Dr Vidal brought before the Society 
of Biology a fact of this nature. The patient was a woman twenty-six vears 
of age, of'^weak constitution, chloro-ansemic, who was admitted into the notel- 
Dieu, suffering from most severe pain, the result of a large and deep cauterisa- 
tion. By an inconceivable carelessness, the person who attended her had made 
a mistake as to the bottle, and, instead of tne liniment ordered, had employed 
in frictions part of the contents of a bottle of the acid nitrate of mercuir. The 
frictions had been made with a piece of linen saturated with the liquid, and in 
spite of the patient's cries of pain, had been persisted in for five or six minutes, 
when the patient was brought to the hospital there was found on the left 
side of the chest, and in a space of the size of two hands, a large eschar of a 
brownish red colour, swelled, and projecting above the healthy parts. Behind, 
and on a level with the left scapula, was a second eschar about the size of the 
hand ; the skin, acutely inflamea, was of a bright red colour, had an ecchyroosed 
appearance, and scattered over it were yellow brown patches ; from this down- 
wurds towards the right haunch proceeded a similar tract about half an inch 
broad, occasioned bv a portion of the liquid having flowed down below the 
limit of the part rubbed. The patient was in a state of prostration and extreme 
anxiety; during the night she had several attacks of bilious vomiting. Dr 
Vidal found her next morning in a most dangerous state ; her skin was cold, 
her features contracted, her eyes sunk, her &ce pale and livid, her voice feeble 
and almost suppressed. The patient had extreme epigastric pain, and suffered 
almost constantly from nausea without vomiting ; she frequently fiiinted. The 
pulse was small, frequent, thready. There was constipation ; the urine was sup- 
pressed. The patient had administered to her a mixture containing rum and 
tincture of musk, as well as warm stimulating drinks. The following morning 



168 PERISOOPE. [AUG. 

she had vomiting of bUiouB matter streaked with blood, and the extremities 
continued cold and cyanosed. The gums were swollen and bleeding ; the buccal 
mucous membrane was red and tumefied, and after visit a very characteristic 
blackish line formed on the free border of the gums, which was very well 
marked around the insertion of the incisor and canme teeth of the lower jaw, 
but was less marked around the molars. The belly was flaccid; consti- 
pation continued. The patient made no water ; the bladder was empty. Vo- 
mitins continued in spite of the use of ice and Seltzer water. On the fourth 
day after the poisoning, the eschars, sun-ounded bpran inflammatory border, began 
to be detached. The matters vomited were glairy and tenacious, but vomiting 
was rather less frequent than before. On the sixth day vomiting had ceased, 
but diarrhoea was severe and accompanied with colic. The patient complained 
of extreme weakness, dizsiness, ana ringing in the ears. The coldness of the 
surface persisted, the pulse was 140, small and thready. Durine the following 
day the weakness increased ; the voice was almost suppressed, the patient onl^ 
answered by signs when attempts were made to rouse her from the semi- 
comatose state in which she lay. She died quietly on the ninth dav after the 
accident, at three o*clock in the afternoon. On post-mortem exammation, the 
mucous membrane of the stomach had an arborescent red appearance, studded 
with ecchymotic patches. The same ecchymoses were round throughout 
nearly the whole intestinal canal and in the urinary bladder. The blood was 
black and fluid. On microscopical examination, the renal parenchyma was 
found much injected, especially in the neighbourhood of the Malpighian bodies ; 
the epithelial cells were irregular in shape, granular, and partially destroyed. 
M. Flandrin, who undertook the chemical analysis, found a sensible quantity of 
mercury in the liver, but no trace of it in any of the other organs. 

The above observation is interesting for several reasons. It is a very re- 
markable example of poisoning by the external application of a caustic salt of 
mercury. It is one of the cases of mixed poisoning, where the substance em- 
ployed, consisting of a salt of mercury and an irritant and corrosive acid, nves 
rise at once to irritant and specific symptoms. Special attention should be 
directed to the existence of ecchymoses in the intestinal and vesical mucous 
membranes, and to the change in the kidney, which was evidently produced by 
the elimination of the toxic agent. The epitheliel cells, granular and altered 
in shape, obstructed the tubes and prevented urinary excretion. This granular 
fatty condition of the renal epithelium is analogous to the lesion regarded as 
characteristic of poisoning b^ phosphorus. M. Potain has also found it in a 
case of poisoning by ammonui. We must then be carefulmot to speak of this 
lesion as characierigtic of poisoning by phosphorus. No doubt^ fatty degeneration 
of the liver and kidneys takes place very readily in poisoning bv phosphorus, 
but other forms of acute poisoning may give rise to the same lesion. This, 
then, is a lesion which is to be attributed not. to a particular kind cf poison, 
but to a form of poisoning. When corrosive substances which have been ab- 
sorbed are eliminated more or less slowly by the kidneys, the liver, the glands, 
etc., they produce an anatomical alteration of the elements of the organs which 
they traverse, and fatty degeneration b the most frequent of the lesions so 
produced. — GtuteUe dee Hopitaux, 

POISONING BY DiaiTALIS. DEATH ON THE FIFTH DAY. BY DR MAZEL. 

ViCTOiRE Z., servant with an apothecary, generally of good health, sent for 
me on the l(Hh of March 1863, about five in the afternoon. She compUuned 
of lassitude, violent headache, and pain in the pit of the stomach. She had 
had a cough for about a week, and said that a cold had taken away her appetite. 
Since the previous evening she had vomited a great deal, and felt herself much 
worse. She attributed her uneasiness and the vomiting to indigestion, occa- 
sioned by having eaten some chestnuts the previous day. I found the skin cold, 
the pulse 52, of fair strength, but irregular, and with frequent intermissions. 
The face was pale, the pupils dilated. The tongue was slightly coated, the 
thirst considerable, tbe epigastric pain was increased by pressure. The belly 



1864.] MEDICAL JURISPRUDENCE. 169 

was patnleM, there wm no diarrhoM. There was a little cough, but on aasciil- 
tation and percuBsion there was no sifn of a pulmonary lesion. I considered 
the case a very serioas one, but could not make a precise diagnosis ; while 
waiting till further observation should enlighten me, 1 endeavoured to combat 
the existing symptoms and the deficiency of reaction by sinapisms applied to 
the lower extromities and infusions of lime-fiowerii. On Wednesday the 1 1th of 
March, the third day of her illness, I found that the patient had not slept at all 
during the night. The Yomiting had recurred as often as she had taken any- 
thing. The pulse was 52, and presented the same characters as before. The 
temperature of the skin in those parts exposed to the air was lower than natural. 
The pupils were still dilated. She was ordered lemonade, and a mixture con- 
taining ether and laudanum. Strong mustard pKOultices were directed to be 
i4>plioa frequently to the lower limlM ; those which had been applied on the 
previous eyening had been scarcely felt. On returning in the course of the 
morning, Mr X., the apothecary, exclaimed, *' The cause of her illness has been 
discovered, the unfortunate eirl has been poisoned with infusion of digitalis.** 
He then informed me how the discoyery liad been made. The house porter, 
while putting the kitchen in order, had round two pots, each containing several 
large leaves, which he thought resembled di^talis ; without attaching any^ im- 
portance to the ctrcamstance he mentioned it to the apothecary, merely with a 
view to know whether he might clean the vessels. Mr X., who had had no 
preparation of the kind to make, had the leaves brought to him, recognised 
them as digitalis, and immediately saw the connexion which existed between 
the infusion and the illness of his servant. On seeing them I also recognised 
the leaves in each yessel as digitalis, and by weighing an equal number of dry 
leaves I found that about fifty grains had been used to prepare each infusion. 
From this moment all was explained, the slowness, irregularity, and inter- 
mittence of the pulse, the coldness of the skin, the headache, tne epigastric 
pain, the constant vomiting, and the muscular debility. I went immediately to 
the patient and asked her if she had taken nothing which could have caused 
her illness. She told me that on Monday she had prepared two infusions of 
borrage for her cold, and that she had drank the firat at eight, the second at 
nine o*clock in the morning. On asking where she had got the leaves, she 
indicated in the most natural manner the box containing digitalis. I informed 
her that she had made a mistake, and that her impruoence was the cause of 
her illness. I have since heard that in spite of the strict and repeated injunc- 
tions of her master, she had, on several former occasions, taken articles out of 
the shop. According to the patient's statement the following was the history 
of the case : — Up to twelve o'clock she experienced no uneasiness, and after 
having served tne dinner she ate some chestnuts. A little afterwards she 
felt uneasy, and had an inclination to vomit. She went up to her room, 
meaning to lie down, but 'almost immediately vomiting came on, at first 
of alimentary matter, then liquid, finally of a greenish-yellow colour. She felt 
cold all over, had vertigo and dimness of sight to such a degree that she could 
not come downstairs the whole evening. She had not urinated, and there had 
been no movement of the bowels firora the time that she had lain down. She 
felt bruised all over ; felt as if drunk, and vision was still indistinct. There 
was no ringing in the ears. There was a soft blowing murmur with the first 
sound of tne heart. I continued the previous treatment, which seemed to 
ftilfil aU indications. In the eyening she was in the same state. On Thursday, 
the fourth day of her illness, I found that the patient had made water about 
eleven o'clock on the previous night, and also towards morning ; the bowels 
had not been opened. Tlie yomitmg continued ; her pulse was slower, being 
only 41 or 42 in the minute. The respiration was embarrassed ; its frequency 
was 16. The patient had still vertigo, and felt as if drunk and fatigued. She 
was ordered vinegar and water, frictions of yolatile camphor liniment, sinapisms, 
and the mixture as before, an enema with an ounce of sulphate of soda. In 
the evening the pulse was 46, stronger. The vomiting was less frequent. She 
was ordered a tablespoonful of soup, with wine every two hours. On Friday 
VOL. X.— NO. n. V 



170 PERISCOPE. [AUG. 

the 13th of March, the fifth day of her illness, the pulse was 58, less irregular. 
Nevertheless, her face had a heavy expression, and the patient, when questioned, 
said she was in the same state as the evening before. The vomiting was less 
frequent. Urination was performed freely. She was ordered another purga* 
live enema. Since the previous evening Y ictoire Z. had complained of lumbar 
pains, and she stated that she was at a menstrual period. Menstruation came on 
m the course of the afternoon. The pulse was now 60, and was neither irregular 
nor intermittent. The wine and soup had generally been retained. The first part 
of the night was passed very comfortably ; at two o'clock in the morning the 
patient got up alone to make water ; on returning to bed she suddenly fainted. 
The persons in attendance rushed to her, but found that she gave no sign of 
life. I was sent for immediately, and although death appear^ to me to be 
real, I Imd ene^etic frictions practised over the region of the heart and the 
extremities. Everything proved unavailing. A post-mortem examination 
was not obtained. 

The above case seems to me important in several respects. In the first 
place, the value of vomiting, as a diagnostic sign of poisoning, should be noted. 
When, in addition to vomiting, there is pallor of the face, coldness of the skin, 
muscidar feebleness, and derangement of^ vision, doubt is no longer permissible ; 
we may be sure that we have to do with a case of poisoning. If I had 
attached to this symptom the importance it deserved I should probably not 
have misunderstood the phenomejia I observed at my first and second visits. 
The idea having once occurred to me, I would have minutely questioned the 
patient, and I have no doubt that she would have given -me the informa- 
tion which accident at last afforded, and which her own statements con- 
firmed. Still, it is singular that she had not suspected the cause of her illness, 
and that she did not mention the pretended intusions of borrage. The time 
which elapsed between the swallowing of the second cup and the occurrence of 
the vomitme probably deceived her, and caused her to attribute all her suffer* 
ings to indigestion. What I have said regarding the diagnostic value of 
vomiting is especially true with regard to poisoning by di^taUs and its active 
principle. The above observation is a typical case of poisoning by this sub- 
stance. I have mentioned, with regard to the nervous symptoms, general 
feeling of coldness, prostration of strength, persistent feeling of drunkenness, 
headache, vertigo, confusion of sight, dilatation of the pupik, ansesthesia. In 
regard to the digestive system, there was constant vomiting, constipation, sup- 
pression of urine. In connexion with the circulation, there was pallor of the 
tkce, coldness of the skin, slowness, irregularity, and intermittence of the 
pulse, a blowing murmur with the first sound of the heart. Most of these 
symptoms are mentioned in works on toxicology. But there is one which, so 
far as I know, has not been noted, and on which it seems proper to fix the 
attention of observers — I mean the suppression of urine. In the case under 
consideration this lasted for fifty hours. It seems singukr that digitalis, the 
diuretic effect of which is so well marked, should, when given in a poisonous 
dose, suppress the function which in a medicinal dose it stimulates. This 
suspension of the urinary function is at once the consequence and the measure 
of tne profound perturbation exercised on the system by the absorption of the 
poison. The same symptom is observed in severe cases of cholera, and its 
persistence is a very bad sign. 

The death of Yictoire Z. did not take place till the fifth day. At my last 
visit there was a marked amelioration ; the pulse had risen from 41 to 60 ; its 
irregularity and intermittence had disappeared ; menstruation had come on ; 
the vomiting was much less frequent ; urination was copious ; and finally, for 
twenty-four hours the patient had been taking soup and wine. Death occurred 
suddenly at two o'clock in the morning. To what cause was it to be ascribed ? 
Was it the direct result of the poisoning, or was it due to syncope ? I believe 
that the latter explanation is correct. No doubt, digitalis, from its special action 
upon the heart, has a special tendency to produce syncope, and it is on account 
or the therapeutical deduction that I make the distinction. In similar cases 



1864.] MEDICAL JURISPRUDENCE. 171 

our endeavour should be to obviate the tendency to syncope, which is to a 
certain extent in our power. If such a case occurred to me again, I should 
direct the horizontal position to be strictly maintained until convalescence was 
perfectly established.— GaaeUe des H&piiaux. 

POISONINQ BY DIOITALINE. BY DR LEFORT. 

Db Jules Lefort brought before the Imperial Academy of Medicine a paper, 
entitled ^* Chemical and Tozological Researches on Digitaline," of which the 
following are the conclusions : — 

1. In France two kinds of digitaline are employed in medicine, which possess 
very different physical and chemical properties. The one is called German, or 
soluble ; the other French, or uisoluble. 

2. Soluble di^taline is coloured green more slowly and less strongly by 
hydrochloric acid than the insoluble form. 

3. Hydrochloric gas colours insoluble digitaline of a deep green, the soluble 
of a dark brown. 

4. The same gas develops with insoluble digitaline the special odour of the 
powder or alcoholic tincture of digitalis ; with soluble digitaline the character 
IS less appreciable. 

5. Under the microscope, in the case of soluble digitaline, we see traces uf 
crystals without a determmate form ; in the case of insoluble digitaline we see 
an opaque magma representing a mixture of at least two substances. 

6. Soluble mgitaline appears to be a purer and better defined substance than 
the insoluble. 

7. The principle which Is coloured green by hvdrochloric acid appears to be 
independent of the digitalme itself, whether soluble or insoluble ; it is no doubt 
volatile, and the same which communicates to digitaline its peculiar odour. 

8. The two kinds of digitaline dissolved in water and in alcohol pass through 
colloidal membranes, and may be separated by the dialytic process from biu>- 
stances which contain them naturally or accidentally. 

9. The bitterness of digitaline, soluble or insoluble, its coloration by 
hydrochloric acid, the odour of digitalis elicited by hydrochloric gas, are cha- 
racters which permit us to affirm its presence in substances which contain & 
moderate quantity of it. — Eeoue de TMrapeuHque Midtco- ChtrurgicdU, 

CHRONIC POISONING BY TOBACCO. BY DR LE BRIERT. 

On the 7th February 1864, 1 was sent for to see a woman, the wife of a miller, 
forty-six years of age. She had originally been of sound constitution, had been 
married twice, and had had ^wt children. She had suffered much from anxiety 
for a long time, but four years ago she had additional grief from the loss of a 
daughter eleven years old, to whom she was devotedly attached. From that 
time she had no peace of mind. She sought every means of distraction, drank 
to excess, and from a singular depravation of taste, took to eatins tobacco of 
every kind, to the amount of about two francs* worth a- week. Wnen I arrived 
the patient was almost speechless *, her voice was hoarse, and she could only 
murmur some inarticulate sounds. The respiration was difficult, sighing ; the 
pulse was weak and slow. The heart scarcelv beat. The pupil was diUted 
and insensible to light ; the eye had a haggard appearance, ana blindness was 
almost complete. Deafness was not complete, but nearing was very dull. The 
face was emaciated, pale, and stupid- looking; the tongue was tremulous, red, 
and dry. Swallowing was very painful, owine to spasms of the throat. The 
belly was retracted. The £»ces, resembling the excrements of sheep, had for 
long only been passed after the use of enemata and purgatives ; at first, on the 
contrary, purging had been present, and she had often vomited. Soon, how- 
ever, her appetite had failed, the gastro-intestinal walls had been, so to speak, 
affected with stupor, like all the rest of the body, and the period of prostration 
arrived. The urine was passed involuntarily. There was weakness, cold 
sweat, sleeplessness. Under these circumstances I could do nothing ; I merely 
ordered soup, coffee, and acid drinks. Wlien I saw the patient two days after- 



172 PERISCOPE. [AUG. 

wards, her voice was suppressed like that of a cholera patient, deglutition was 
impossible ; the chest scarcely moved ; the respiratory murmur and the move- 
ments of the heart were almost inaudible. All the organs were in a manner 
stunned by the influence of the tobacco. Death occurred a few hours after- 
wards. — wzeUe dea H6pijtaux, 

POISONING BY TOBACCO LEAVES. BT DR NAMIA8. 

Some time ago, M. Decaisne laid before the Academy of Sciences a memoir 
on '* the intermittence of the heart and pulse occasioned by excessive tobacco 
smoking," in which he arrived at the conclusion, that the abuse can produce in 
certain persons a condition which may be called narcotism of the heart, and 
which manifests itself by intermittence in the beating of the heart, and in the 
pulsations of the radial artery. The importance of bringing forward facts in 
connexion with this theory, induces me to record the following case. A smuggler 
some months ago covered tne whole of his naked body with tobacco leaves, with a 
view to defrauding the revenue of the amount of the duty. The tobacco, moistened 
by perspiration, produced through the skin a real poisoning, which, however, 
was cured by means of alcoholic stimulants and laudanum. The extreme 
feebleness of the pulse, its smallness, the cold sweats, the fainting occasioned 
by the tobacco applied to the whole surface of the body, present numerous 
analogies with the condition called by Decaisne narcotism of the heart, and 
which he noticed to disappear entirely or to diminish when the use of tobacco 
was suspended or diminished. So far as I know, no other case of poisoning 
by tobacco applied to the skin has been recorded. The treatment successfully 
employed does not, however, lead to any general conclusions. In ordinary 
poisoning, the first thing is to eliminate or neutralize the poison. We must 
then direct attention to the condition produced b)r it, and this condition 
depends not only on the nature and quantity of the poison, but on the previous 
condition of the individual. We cannot thus treat poisoning by the same 
poison in different individuals in the same manner, because the same morbific 
causes do not always produce the same consecutive malady. Electric currents, 
which in other conditions excite hyperomia and inflammation, only exhaust 
and use up directly the vital forces when they act with too great violence. I 
have made a similar observation as to the efiect of alcoholic stimulants, which 
must be combated according to the different symptoms presented by the 
patients, that is to say, according to the different diseases which are the con- 
sequence of their abuse. — Oasette de$ HSpitaux. 

ON THE DELETERIOUS EFFECTS OF ANILINE ON THE WORKERS WHO PREPARE IT. 
BY DR KREUSER OP STUTTGART. 

The author observed in the Catherine Hospital of Stuttgart several cases of 
intense bronchitis, characterized b^ a violent dry spasmodic cough, accom- 
panied by ulcerations, situated especially on the scrotum and lower extremities, 
of a rounded form, with borders sharply cut, often callous, covered with thick 
black crusts, under which was a base of a dirty grey colour, the surrounding 
parts being swollen and painful. All this yielded readily to a simple treatment 
so soon as the workmen were removed from the manufiictory where the colour 
was prepared. If care were taken to protect the skin by suitable clothing, by 
raakinff the workmen wash frequently, and by improving the ventilation, these 
bad efrects might be avoided. The existence of this peculiar affection haa been 
also observed by MM. Stadler at Marbourg, and Stoerig at Wildnngen. — 
Eeme de ThfyxtpeuHque MicUoO'Chirurgicale. 



^ 1864.] MEDICO-CHIRUBaiCAL 80CIETT OF EDINBURGH. 173 



MEDICAL NEWS. 



MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH. 

SESSION XLIU.— MEETING Vin. 

lit June 1864.~Dr Douglas Maclagan, President of the Society, in the Chair. 

I. AMPUTATION AFTER EXCISION OF WRIST- JOINT. 

Mr 8pmc€ showed a specimen from a man in whoin amputation of the fore- 
arm haa been performed. He had, about the beginning of winter, excised the 
wrist-joint by means of two lateral incisions, with a view to leave the tendons 
untouched. At the time of the operation there was no disease of the radius 
or ulna, the caries being confined to the carpal bones. For a time everything 
went on well, and the patient was sent to the Convalescent House. After a 
time, however, the ends of the bones of the fore-arm were found to be bare. 
Mr ^pence hoped that there would only be thin exfoliations, and that when 
these came away the patient might still have a useful hand. Unfortunately, 
necrosis extended up the shafts of the bones, hssmorrhage in consequence of 
ulceration of vessels took place, and amputation was required. Mr Spence 
stated that though the result in this case had been unfavourable, it would not 
deter him from repeating the excision in a proper case. The man at the time 
of the operation was not in a very favourable state for it, being weak and 
amsmic. Since the amputation all had gone on well. 

U. REMOVAL OP WHOLE SHAFT OF TIBIA. 

Mr Edwards showed a tibia which he had removed about a month ago, while 
taking charge of Dr Gillespie's wards in* the Royal Infirmary. The patient was 
a man forty years. of age, and had su£fered from ulceration of the tibia for many 
years ; at times there had been much pain, and diseased portions had been 
gouged out again and again. The diHease, in fact, seemed mcurable, and Mr 
Edwards 4iad accordingly performed an experiment which, if successful, would 
turn out to be important. He had removed the whole bone, leaving only the 
periosteum as entire and as thick as possible. This had been done more easily 
than might have been anticipated. The wound was now nearly healed. 'Hit 
Edwards hoped that the fibula would become h^ertrophied, and that bone 
would be deposited (as after compound fracture) m the interosseous membrane 
and from the periosteum ; so that if there was not a new tibia, there might at 
least be a firm bony rod of some description, which would allow the man to 
retain his l^, and be better than a wooden one. Since the operation the man 
had been quite free from the old pain. 

III. MALIGNANT DISEASE OF THE FEMUR. 

Dr Brtioe showed a specimen of malignant disease of the thigh bone, re- 
moved a few days ago from the body of a man sixty-three years of age. For 
about a year the patient had complained of failing health. There haA been 
obscure symptoms simulating neuralgia, but not yielding to treatment. A few 
da^s before death a swelling made its appearance in the anterior aspect of the 
thigh ; it seemed to be a tu.aour arising from the bone. It continued in much 
the same stat6 for a week or tfo, when the femur broke while the patient was 
being carefully removed to bed. Dr Bruce saw him at this time, and found 
the symptoms of fracture evident. The patient became weaker and weaker, 
and at length sank. On post-mortem examination, a mass of malignant disease 
was found growing from about the middle of the femur. The bone seemed to 
have been very much destroyed. 



174 MEDICAL NEWS. [AUO. 

IV. CYSTICERGUS CELLULOSES IN BACON. 

Dr R. Peel RUcMe showed a specimen of measly bacon. A friend in London 
had noticed that some bacon which he had got for family use had an anhealthj 
appearance. He sent a little bit of it to Dr Ritchie, who, on microscopic 
examination, detected numerous booklets of the cysticercus. Dr Ritchie 
accordingly wrote up that the meat was unhealthy, and requested to be supplied 
with a larger specimen of it. The portion now exhibited was accordingly sent 
down, and in it could be at once recognised numerous cysts of the parasite. 
Although there was not much danger to be apprehended, as an^ of the bacon 
which had been eaten had been thoroughly cooked, Dr Ritchie had thought 
it advisable to recommend the three members of the family who had partaken 
of the bacon to have a dose of the male shield-fern. Only one, however, had 
taken it. A second took an aperient pill ; whilst the third declined taking any 
medicine. None of the family had suffered any bad effects. Thb Dr Ritchie 
attributed partly to the bacon being cooked, but chiefly to its being well 
cured. 

y. TRACHEOTOMY IN DIPHTHERIA. 

Dr Joiqph Be2/ showed the air passages in a case of diphtheria in which he had 
performed tracheotomy. At the time of the operation the respiration was much 
embarrassed, but after its ]3erformance the breathing was much relieved, and 
continued so until death, which took place on the third day, not by asphyxia but 
by asthenia. On examination, a great deal of false membrane was found in the 
tiachea and extending beyond its bifurcation into the bronchi. The case on 
the whole, was rather calculated to encourage the performance of the operation, 
as showing that relief was afforded even when false membrane was deposited 
below the opening in the windpipe. On post-mortem examination the cause 
of weakness was discovered in deep and extensive sloughing of the tonsils. 
This condition also expUmed the sort of pyemic odour which was felt soon after • 
the operation. 

yL DISEASE OF DECIDUA. 

Dr Gamgee exhibited a specimen illustrative of extensive disease of the 
maternal and foetal portions of the ovum. Mr A. Miller had been sent for, 
three weeks ago, to see the inmate of a brothel who had had sb'ght uterine 
pains for twenty-four hours, and was then suffering from haemorrhage. Shortly 
after Mr Millers arrival the mass now exhibited to the Society was expelled. 
Its shape was pyriform, and resembled a rather enlarged uterus. The woman, 
it should be mentioned, considered herself four months gone. On incising the 
mass, Dr Gamgee at first failed to detect any trace of an embryo ; he merely 
saw a cavity lined with a sort of serous membrane. On very carefltl examina- 
tion, an embryo at a very early stage, presenting the characters of the third 
or fourth week, was discovered. The head, upper and lower extremities, could 
be distinguished, and black spots for the eyes could just be distinguished. The 
length of the embryo was about three or four lines. The mass consisted bf 
a number of little cysts; the outer surface seemed covered with muscular 
tissue, but no true muscular fibres could be detected, and the appearance was 
probably caused by the peculiar cells of the decidua. In this case there had 
no doubt been hypertrophy of the decidua, with cystic degeneration. It was 
very probable that impregnation had taken place four months before the 
expulsion of the mass, but the disease of the decidua had arrested the develop- 
ment of the embryo at an early period. 

VU. DILATATION OF THE (BSOPHAOUS. 

Dr Alexander Wood exhibited a very remarkable preparation illustrative of 
dilatation of the CBSophagus, the particulars of which will be given in a future 
number of this Journal. 



1864.] 06STETBICAL SOCtETT OF EDINBURGH. 175 

PROCEEDINGS OF THE EDINBURGH OBSTETRICAL SOCIETY 

SESSION XXIII. — MEETIKO YUI. 

I3th April 1864.— Dr Pattison, Vioe-Prtrident, in the Chair. 

I. ON SOME INSTBUMENTS TO FACILITATE THE INTRODUCTION OF TENTS AMD 
DILATATION OF THE 08. BY DR KEILLER. 

In exhibiting these instrnment^, Dr KnUer remarked, that at the previous 
meeting he had referred to the difficulty which was experienced in introducing 
tents, and that he had devised an instrument to facihtate their introduction. 
Since then he had been working at the matter, and had now obtamed instru- 
ments which would not only be serviceable for that purpose, but which would 
also be of use in aiding the dilatation of the os. Tne first instrument was a 
pair of curved forceps, fashioned after the form of a sound, and marked like 
that instrument, so tnat it might be used for similar purposes in ascertaining 
the position and size of the uterus. As a pair of forceps, you could grasp a 
tent with it, and by this means much more easily introduce it. He might here 
remark al^o, that he had found it of great benefit to give the tangle-tent a 
slight curve. It not only facilitated its introduction, but kept it much better 
in position when introduced. For using the instrument for the purpose of 
dilating the os, by opening the blades when once introduced within the os, he 
had put a flattened point upon one of the handles, against which you could 
press with the thumb, and in that way exercise a much greater lever power. 
The second instrument was a grooved probe-pointed curved director. In using 
it, yon first introduce the point into the os, and then, by passing the tent along 
the groove, it readily enters within the cervix. The groove, he found, 
answered best when placed on the convex surface. This instrument was also of 
great service in cases where the os was very high up and far back. In ex- 
amining such cases there was often very great difficulty, but with this instrument 
von could draw the cervix well down and forwards. It might also be of use in 
bringing the os into view when using the speculum, by first introducing the 
instrument and then passine the speculum over it. For the purpose of 
using the instrument as a dilator also, he had made a sound to correspond 
with the curve, and to fit in the groove. The points of both director and 
sound having been introduced within the os, you could dilate by separating 
them in the manner of a paur of forceps, and when the handles came in contact 
you could still further increase the distance between the points by virtue of the 
curve in the instrument, by pushing the director further along the groove. 
The disadvantage of these instruments in dilatation was that their dilating 

Sower was in the antero-posterior diameter, but by changing their position 
uring their introduction lateral dilatation could also be accomplished. Dr K. 
was lulling an instrument made after the plan of a glove-stretcher, by which 
you could dilate in any direction. 

Dr Alex, R, Simpion having had no experience in the method proposed by 
Dr Keiller, of forcibly dilating the os, was unwilling to express an opinion on 
the use of the instruments for that purpose. Thev seemed to be very mgenions 
and practical, but it appeared to him that all that was wished to be attained 
by them was attainable by the slower, and — he could not but think— safer, 
method of using the tents. Gradual dilatation seemed to him, a priori, better. 
The fancy for rapid dilatation of the os uteri by means of instruments, how- 
ever, seemed to be becoming general; for Dr Priestley, in London, and an 
Australian physician, Dr Wilkie, of Melbourne, had lately proposed instruments 
for that purpose. In reference to the speculum, he mi^t mention that the 
most serviceable form was that of the bivalve, made so as to dilate the vagina 
in the antero-posterior diameter. 

Dr Myrtle thoiu^ht that as there was often great pain in the use of the tents, 
there would be stul greater in the method proposed by Dr Keiller. 



176 MEDICAL NEWS. [AUO. 

Dr Bum asked what object Dr Keiller wished to obtain by the forcible 
dilatation of the os which could not be attained by the tent ? 

Dr KeSier explsined that the principal object ne had in view by the ase of 
his instruments, was to facilitate the introduction of the tents. Also, in the 
examination of the uterus, to enable one to draw down the os in cases where 
it was high up and inclined very far backwards. With his director he was 
able to ^braw it well down and forwards. Their use for the forcible dilatation 
of the OS he only proposed in cases where you wished to spare time. He by 
no means intenaea by it to supersede the use of tents where you had time at 
your disposal. Another advantage was that the patient did not require to be 
confined to bed, as she frequently did in the use of the tents. The ^eat object, 
however, was to facilitate the introduction of tents, and, by making the one 
instrument serviceable for other purposes, increase their use by simplicity of 
structure. 

n. CASE OF PUERPERAL SCARLET FEVER. 

Dr Bruce read the following histoiy of the case : — Mrs C. was confined on 
the 22d February last, the labour bemg of an ordinary character, and every- 
thing going on well until the 26tb, when she felt not so easy, and complained 
of headache, and at night became very feverish and restless. On seemg her 
next day I found that there was a scarlet eruption comibg out all over the 
body; the pulse was 150. Next day, the 28th, the eruption was well out, 
pulse still l50, and there was a tendency to delirium. z9tA, There is now 
much delirium; pulse 160, and weak; she cannot speak well; eruption keeps 
out. Ammonia, beef-tea, wine and brandy given to combat the weakness, 
which is becoming very marked. March 1</, pulse 160. There was much 
delirium through the night. Patient lies in a kind of stupor, but still appears 
to be so far sensible ; at night the pulse rose to 166. The stimulants continue 
to be given very freely, but without much effect, and she died early in the 
morning of the 2d. 

Dr Cappie stated he had met with one case where the patient recovered 
from the fever, but sunk afterwards, from the complications of post-scarlatinal 
albuminuria. 

Drs Ziegler and Stqthenson had both had cases which recovered. 

m. MOTE ON THE MANAGEMENT OF THE THIRD 8TAOE OF LABOUR. BY HR 
ALFRED M. WATSON. 

Dr Alexander R. Simpean beeged to remind the Society, that in debating the 
history of a case of complex labour at a recent meeting, ne had taken occasion 
to speak of the practice that had been coming into vogue in Germany, of effect- 
ing the immediate expulsion of the placenta by external compression of the 
uterus. It was nothing new to British practitioners to manipulate the uterus 
frpm above the pubes, with a view to expedite the extrusion of the after-birth, 
and the results of this practice in the hands of such men as Dr Lawrence, of 
Montrose (see this Journal for March 1863), showed the importance of hav- 
ing recourse to it very speedily after the birth of the child. But, so far as 
he was aware, few or none had been in the habit of effecting the delivery of 
the placenta toithoui inierfering toith the cord, with the exception of Dr Newman, 
of Stamford ; and, as Mr Alfred Watson, a talented pupil of that gentleman, 
bad kindly made a note for him of the results in 200 cases treated in this way, 
perhaps the Society would allow him to read them : — " The plan,^* says Mr 
Watson, " which I have followed in the followinff cases is founded upon the 
method described by Dr Newman, in the British Medical JoumaL But I do 
not follow his plan entirely. He contents himself with merely extruding the 
placenta and membranes into the vagina, and then extracting the mass 
from the vagina by erasping the edge of the placenta and withdrawing it, 
I endeavour to extruae the whole mass from the vagina as well as from the 
uterus, by continued grasping and occasionally compressine the uterine 
tumour, and in this I usually succeed. In order to accomplish this it is 



1864.] OBSTETRICAL SOCTBTT OF EDINBURGH. 177 

neoesaary that the nteniB should be grasped in the hand and kept firmly 
compressed very shortly after the removal of the child. The pressure should 
be oontinaed, and the nterine tmnonr manipulated through the abdominal 
walls. It causes very little inconvenience to the patient, is done without 
at all exposing her person, and need not be very ]^inful. It is worthy of 
remark here, that the larger the hand of the practitioner, and the firmer and 
more complete the grasp of the uterine tumour, the sooner is the expulsion. 
There need not urdinarilv be any difficulty in finding the tumour, if the hand 
has been employed in fouowmg the descent of the diild during its expulsion. 
It is almost alwa;^s in the right iliac fossa, just beneath the margin of the hip. 

'* It only remains for me to state, that by following this procedure I have 
saved myself much trouble, and have usually succeedra in expelling from the 
uterus and vagina the placenta and membranes, without the necessity of 
making any traction on tne cord ; indeed, after the ligature has been applied I 
find myself in a position to ignore altogether the existence of that appendaoe. 

** Further, let me state tmit I have attended considerably over a hundred 
cases of midwifery, where I was obliged to follow the old rule of treating the 
expulsion of placenta with unaided uterine effort ; and I feel convinced of the 
superiority of the method which I have endeavoured to describe. 

*' The nature of the cases wUl be best shown by the following statement : — 
*' Presentation, — Cranial, in 183 cases ; breech, in 5 ; footling, in 5 ; placenta 
pnevia, in 1 ; premature labour, in 4; not noted, in 1 ; hand and funis, 1.-^ 
Total, 200. 

<* Metllod of delivery, — Bv natural efforts in 194 cases ; by forceps, 3 ; by 
turning, 2 ; by craniotomy, 1. — ^Total, 200. 

" RanUi9. — Post-partum hssmorrhage in 1 case. Adherent placenta, requiring 
the introduction of the hand to peel it off, occurred in 1 case. I have not 
had a single case of ' hour-glass contraction.* 

'* The case in which post-partum hemorrhage occurred was that of a woman 
who was the subiect ot oiganic disease of the heart (aortic insufficiency), and 
who had suffered from alarming hemorrhage in her two previous labours. 

^ The usual duration of the tnlrd stage in these cases was from Jifteen to twmty 
Mtnutea, Occasionallv it was prolonged over half an hour, but very rarely. 
In the 200 cases it oiuy occurred to me to be detained over an hour, owing to 
the placenta, in 4 cases (besides the hemorrhage case), — one of these being that 
in which the placenta was adherent. 

" In the 200 cases I lost 2 cases ; these patients resided in the same street in a 
small town, they were confined on the same day, and they died within a few 
hours of each other of puerperal fever, which was then epiaemic, and causing 
a mortality among lying-in women. 

" Except the 2 version cases, 1 forceps case, and the craniotomy, I conducted 
the labour. In all, I had charge of the third stage. 

" Some of these cases occurred in Lincolnshire, some in Sussex, and a few in 
Dublin." 

Dr Bum stated that he had tried the method mentioned in the paper in 
eight or ten cases, but had never succeeded in ejecting the placenta oy it. 
In the last case he found that a larse portion of the membranes was retained. 

Dr Bryoe remarked that t]tie methoa he had for some time adopted was usinff 
only one ligature, and allowing the placenta to empty itself of blood. He had 
found it very serviceable in facilitatmg the expulsion of the pUcenta. 

MEBTINO IX. 

27^ AprU 1864.— Dr Pattison, Vke-l^reMaU, in the Chair. 

I. CASE OF PUERPERAL CONVULSIONS. 

Dr Keillor read the following notes of a case, by Dr Gordon of Juniper 
Green : — On the 5th of February last, about nine in the morning, I was called 
to attend a young unmarried woman in labour, — first child. She had been 
ailing all night, but not very iU. On my arrival, I found her in bed, having 

VOL. X,— NO. II. as 



178 MEDICAL NEWS. [aUO. 

occasional pains, bnt not strong. On examination, I found the os uteri dilated 
to about the size of half-a-crown, head presenting. I did not deem it necessary 
to wait. I made some visits, and returned in about two hours. During my 
absence, pains had become more severe, and her mother told me that she had 
had " a queer turn of the nerves," she thoi^ht. This amounted to a little 
incoherent talk, and a little staring at the roof of the bed. I remained a little ; 
during that time she had a pkin or two, and after one of them a fit of convul- 
sions (epileptic). By this tune the os had dilated to the size of a five-shilline 
piece. After a few more pains she had another fit. I then bled. This seemed 
to have settled both labour pains and fits for an hour or two. Her pains 
began again. As they increased the fits became more frequent and more 
Revere. Finding her pains not strong enough to deliver the child, although 
now the os was fully dilated, I detennmed to use the forceps, which I applied 
verv easily, and delivered without any difficulty. The child was a full grown 
healthy-looking female child. This I hoped would have terminated the con- 
vulsions ; but they continued, and perhaps increased in severity, and never 
abated, in spite of another bleeding, a purge of colocynth and jalap, together 
with a tartar emetic mixture, till the foUowin^ morning about eight o*clock, 
when she died. She was delivered about six m the evening of the 5th. I 
regret I had no opportunity of examining the urine. 

The case is made more interesting to me in consequence of the child having 
begun to take fits the following day, and continued to do so more or less till it 
died ; it lived about twelve days. 

The young woman was aged 21, strong and health;^. She had been promised 
marriage, but the young roan failed to fulfil his promise, which was said to have 
made her dull, listless, and sleepless, for some time previous to her confinement. 
Could this be the cause of the mother's convulsions, or what might be the 
cause? and what connexion between the mother's and the child's? and if any, 
how does the former afifect the latter ? 

Dr PaUiBon concurred with the remark of Dr Gordon, and thought that 
mental anxiety might act aiT a cause of convulsions. 

Profes9or Strnmon said there were, however, many cases of convulsions with- 
out such mental cause. Albuminuria was probably the cause in the present 
case; and he had published some cases where the child was found to suffer 
from albuminuria at the same time as the mother. He might take this oppor- 
tunity of mentioning a case he had lately seen with Dr T. Balfour. The 
patient, very near her full time, suffered from oedema of the whole body, to a 
greater extent than he had ever seen before. Her mind was wandering. All 
aiuretics, etc., had failed ; and her stomach was so irritable that it was impos- 
sible to administer medicine in the ordinary way. Premature labour could 
not be induced on account of the excessive oedema of the labia. He recom- 
mended the inhalation of the oil of juniper. A profuse flow of urine soon 
followed, and the enormous oedema rapidly subsided. The medicine had soon 
to be stopped, to prevent too great irritation of the bladder. The patient was 
shortly after delivered of a dead child, and made a good recovery. 

Mr Pridis had observed three cases of albuminuria, complicated with con- 
vulsions, in which there was a great loss of memory, and inquired whether the 
members had observed the same symptom. The treatment followed was 
bleeding, and large doses of acetate of potass ; in two of the cases chloroform 
was given. All the three cases recovered, but the loss of memory was per- 
sistent for a considerable time ; in one of the cases partial recovery had only 
been attained. 

Profes9or Swipatm said, that French authors mentioned loss of memory and 
amaurosis as a fre(}uent result of albuminuria. He ^Prof. S.) had frequently 
met with it, and in very various degrees. Sometimes a slight degree of 
amaurosis was one of the very first symptoms complained of, earlier even than 
the oedema. Sometimes it occurred late, and remained after all other symptoms 
had disappeared. 

Dr Rudde had seen great benefit derived from injections of salt and water 



1864.] OBSTETRICAL SOCIETY OF EDINBURGH. 179 

in some cases of epileptic conytdsions. They might be repeated when neces- 
sary at the interral of an hoar or an hour and a hiaf. 

IL A CASE OF COMTBACTED PELTIg AND ITS CONSEQUENCES. 

Dr Bryoi (of Dalkeith) related the following case :-— 

At 10 P.M. of the 5th January 1862, I was requested to visit Mrs C, a 
primipara. On my arrival I learned from the midwife in attendance that Hhe 
had been sent for on the morning of the dd,— that she had visited her patient 
at intervals during the three previous days, — ^that the labour during these days 
appeared to her to be going on^ though slowly, but that she had never been 
aole to make out any presentation, and that the pains had entirely ceased on 
the evening of the 4th. 

On makmg a vaginal examination I found the uterus very high up, the os 
pretty well dilated, and the cervix hanging loosely in front of the festal head, 
which was resting on the brim of the pelvis, the occiput on, and projecting 
considerably over the pubis, and the frontal bone on the projecting promontory 
of the sacrum. 

The whole pelvis was found to be an unusually small one in all its diameters 
but chiefly in the antero-posterior, which measured not more than two and 
a-half inches. 

A soft tumour about the sise of a pigeon's egg was felt under the right 
ramus of the pubis, which entirely disappeared on the introduction of a catheter 
into the bladder, and was, in fact, a pouch of the bladder pinched between the 
head and pubis in front, and the heaa and sacrum behind. 

As the patient was hot and restless, with pungent heat of the passages, and 
a frequent pulse, I prescribed some soothins measures, explaining to the friends 
that craniotomy or the csesarean section, I feared, would be necessary, but that 
I should wait for a few hours till the feverish condition was subdued, when 
she would be in a better condition for interfering. I saw her again at 3 a.m. 
next morning, the 6th, — ^found that she had had some sleep, and was much im- 

f roved in her general condition, but no alteration on the progress of the labour. 
saw her again at 7 a.m., when I found that she had enjoyed some more inter- 
vab of sleep— that the fever was subdued and the passages quite cool, but still 
no return of the pains. Considering her now in a very favourable condition 
for instrumental interference, I requested the advice and assistance of Dr 
Lucas, who advised further delay, as there was nothing in the condition of the 
patient to call urgently for immediate delivery, and as he thought there was 
still some prospect of the natural eflbrts — ^if the uterus could be again induced 
to take on action — ^bringing the hcAd into a more manageable position, although 
they might not be able to complete the labour. We accordingly waited till 
1 A.M. on the 7th, when we again saw her together; and as there was even then 
no appearance of the return of uterine action, and no change whatever in the 
condition of t])e case, we decided on at once opening the head ; but the removal 
of the brain and the greater part of the skull producing no appreciable improve- 
ment on the progress of the case after three hours of oft-repeated and fruitless 
attempts at extraction with the crotchet, we requested the assistance of Pro- 
fessor Simpson, who saw our patient at twenty minutes past nine the same morn- 
ing, and delivered her at twenty minutes to ten of a female child, with Scanzoni*s 
kephalotribe. Notwithstandmg the un&vonrable position of the head — ^not 
only above the brim, but thrown a good deal forward by the projection of the 
lower part of the spinal column — Dr Simpson applied the instrument with the 
greatest facility to the base of the skull, the bones of which it speedily crushed 
and so effectually compressed, that the portion of the head still remaining was 
soon brought down into the pelvis and aelivered. The shoulders got as nrmly 
impacted at the brim as the head had been, but the difficulty was soon over- 
come by Dr Simpson hooking down one arm with the large end of the crotchet. 
The uterus contracted well, and in a few minutes the placenta was removed. 

When I saw the patient in the evening, there was some fever, but no 
abdominal tenderness. Next morning, however, she was attacked with pelvic 
cellulitis, and at my visit then there was high fever and delirium, with great 



180 MEDICAL NEWS. [aUG. 

pain and tenderness in the hypogastric redon. On the third day a tumour 
about the sijse of an orange appeared in the right iliac fossa, and on the fifth 
or sixth day violent diarrhoea set in; after which, the tumour rapidly dis- 
appeared. 

At my visit on the ninth day, I found her sitting by the fire, and on the 
eleventh day I discontinued my attendance as she was then quite well. 

Mrs C. again became pregnant in the end of January or early in February 
1863. Professor Simnson saw her the following August, and advised the in- 
duction of premature labour at the end of seven months and a week. I accord- 
ingly induced labour on the 10th of September by dilatine the os and separating 
the membranes. Slight grinding pains came on the following day, and on the 
12th labour was progressing, though slowly. At 8 a.m. on the 13th, I found 
the OS dilated to about the size' of a crown piece, but when I saw her again in 
the afternoon, I learned from the midwife that tne pains had ceased for some 
hours, and, on making a vaginal examination, I found matters in exactly the 
same condition as when I was called to see her in her former labour. In 
order to save the child, I decided on delivering with as little delay as possible ; 
returned at half-past eight, and assisted by Dr Maclaren, I appli^ Simp- 
son*s forceps, and delivered her of a vigorous little girl at twenty minutes past 
nine. The uterus contracted firmly, and in a few minutes expelled the placenta. 
She recovered without a single bad symptom, and was going about agam on the 
third or fourth day. 

On examination of the child^s head, we could discover no trace of forceps 
marks ; but in the scalp, about the middle of the left half of the occipital bone 
was found a small circular ulcer, at the bottom of which the bone was seen 
completely denuded of pericranium, and having exactly the appearance of a 
hole made by a saddler^s punch. At first I supposed that this ulcer must have 
been caused by pressure on some process or exostosis of the pelvic bones, but 
have twice searched in vain for such. The patient has also been carefully 
examined bv Dr Alexander Simpson, with a like result. 

The child nursed vigorously from the first, and was apparently perfectly well 
till the evening of the twelfth day after its birth, when it suddenly uttered a 
piercing cry, which was often repeated throughout the night till the next fore- 
noon, when it died. Twenty-four hours after death I examined the body, and 
on removing the calvarium I found evidences of pretty extensive inflammatory 
action ; the dura mater was adherent to the occipital bone, and opposite to the 
external ulcer above described there was a small denuded point on the internal 
surfiMM of the bone. An abscess also had burst in the same locality, probably 
at the time of the first piercing cry. The viscera of the abdomen and thorax 
were in a normal condition, with the exception of the lungSi both of which were 
studded here and there with dark spots, which on section were found to be 
gangrenous abscesses, the results of pulmonary embolism. 

Profesaor Simpson exhibited a number of kephalotribes which were used on 
the Continent, one of which he used in Dr Bryce*s case. They were aU, how- 
ever, very heavy and clumsy. He had endeavoured to improve upon them, 
and had got an mstrument made, which he also showed, of a similar construc- 
tion, but of much smaller dimensions, being only the length of an ordioary pair 
of forceps. He had not as yet, however, h&d an opportuity of testing it m the 
delivery of a child, but was able to thoroughly break up tne base of the skull 
of a newly-born dead infant. 

Dr Moir said, in many cases where premature labour was induced, he would 
rather apply the forceps even when it was possible than turn. He considered 
it safer to tne child. 

Profesaor Simpson remarked that either means could be adopted in many 
cases, but there were some where the only choice lay between turning and 
craniotomy. 

ra.* ON THE USE OF BROMIDE OF AMMONIUM IN PERTUSSIS. 

Dr E. P. EikMe read a paper on this subject, which appeared in the June 
number of this Journal, p. 1095. 



1864.] TRIAL OF THOMAS ABNOT FOR MURDER. 181 

REPORT OF THE TRIAL OF THOMAS ARNOT FOR MURDER, 

High Court of Justiciary, Gth June 1864. 

By Hugh Cowan, Advocate. 

The prieoner Thomas Amot was placed at the bar charged with the crime of 
murder, in 00 far as on Tuesday the 15tli March 1864, on or near the turnpike 
road, leading from Alloa to Stirling, and at a part thereof situated about 300 
or 400 yards to the westward of the bridge over the river Devon, called Tulli- 
body Bridge, he did wickedly and feloniously attack and assault the now 
deceased David Paton, farm-servant, then residing with Oeorge Henderson, 
farmer, Haugh of Black Grange, parish of Logic, and shire of Clackmannan, 
and did with a shovel or spade, or some other weapon to the prosecutor 
unknown, strike him several or one or more severe blows on or about the head 
and shoulders and other parts of his person, and did otherwise maltreat and 
abuse him ; by all which or part thereof the said David Paton was mortally 
injured, and died on 16th March 1864, and was thus murdered by the prisoner. 

For the Crown the Solicitor - General (Tonng) and Mr J. A. Crichton, 
advocate-depute ; for the prisoner Messrs J. Guthrie Smith and R. V. Campbell, 
advocates. 

Mr Crvthrie Smith stated that he had to inform the Court that the prisoner 
was of unsound mind and not a fit object for trial. 

The following witnesses were then examined : — 

John Gregory Wallace, writer, AUoa. — ^I was consulted by the prisoner's 
wife as to hu defence about the end of April last. The following day I saw 
the prisoner Amot. I told him my name. He said he had heard of me before. 
I told him the object of my visit, saying that I had seen his wife the day 
previous, and she had wishea me to see him as to the charge tu^inst him. I 
explained to him the nature of the charge. He said that if I was to act for 
him as agent I must take steps to brins in the Free Church and the Govern- 
ment for trial along with him. I told nim that this could not be done. He 
said that he was not the responsible person, but that the Free Church was, because 
he had been persecuted by them beyond what any man could bear for the last 
eighteen years, that they had published articles during thatperiod against him 
in the Alloa newspapers, and, indeed, in all newspapers. Tney had concealed 
his name, but he knew quite well that he was meant. He instanced the Car- 
dross case, and said that he was McMillan. I understood him to mean that the 
FVee Church put in Mr McMillan's name, but he was the party meant. He 
said that Mr Goldie of Tullibody was his minister, and that he had preached 
against him for a number of years. On one occasion Mr Goldie made refer- 
ence to a man with a blue coat and a brown bible — that though there might be 
other men with brown bibles he was the only man in the church with a blue 
coat, and Mr Goldie had meant him. He said that Mr Mowbray, distiller, Cambus, 
was at the bottom of the conspiracy against him — that he influenced Mr Goldie 
to preach against him. I asked him what was the object of all this. He said 
that the Free Church wished to excommunicate hun, and if they succeeded in 
doing so the Government would then lay hold of him and transport him to the 
Channel Islands, where he would have to choose between the whites and the 
blacks, and that as he had been so long persecuted by the Christians here he 
'tronld be obliged to join the blacks, which was all the Government wanted. I 
asked him what all this had to do with the case. He said that he had been so 
long persecuted by the church that he wanted to bring the church to its trial, and 
must therefore strike a blow at one of its instruments, and the boy was one. He 
said that the Free Church had used its influence with the Government for the 
purpose of bringing in the millennium. He said that that would never do, 



182 MEDICAL NEWS. [AUQ. 

although it might take place soon. I was with the priaoner about three- 
quarters of an hour. The conTersation was very unconnected. He seemed to 
be quite serious. I called for Dr Brotherston, and requested him to visit the 

Srisoner, and report as to the state of his mind. I saw the prisoner again ten 
ays after. I put some questions to him about the witnesses, and could 
scarcely get any answers from him. I saw him again on 26th May, and could 

get no mformation from him then. He just went over what he told me on the 
rst occasion. On none of these occasions did the prisoner express any 
regret. I do not think he was able to give instructions for his defence. 
Cross-examined. — I had no idea that the prisoner was feigning. He seemed in 
very eood spirits, and said he was very comfortable. The second time I saw 
him ^e prisoner was engaged at his dinner. He took from a little box in his 
cell the indictment, and gave it to me, and then resumed his dinner, and made 
no answer to the questions I put to him. On 26th May the prisoner was in 
much the same state as on the 10th. He would harmy speak, but when I 
pressed him, he @ve much the same account as at the first. 

Rev. WUUam F, GoldU, Minister of the Free Church at Tullibody.— The 
prisoner had been a member of my congregation previous to 1857, when I 
oecame minister, but I don^t think that he communicated after that. On the 
afternoon of Tuesday, 15th March, the prisoner's daughter came to me in my 
house, and said that her father had come home in great distress, saying that he 
had killed a boy. I said to her not to believe her father till the statement 
was confirmed, as he laboured under peculiar fancies. I knew he did so. My 
first idea of this was caused by what occurred at my communion in June 1860. 
Each member when he applies for a token writes his name on a slip of paper, 
which he hands in. The prisoner waited till all the other applicants had USt, 
and then himded in a paper with his name, and under it these words, — "If any 
one have a charge to ormg against me, I am here to answer for myself.*' I 
asked him what charge. He said I knew all about it. I stated there was no 
charge that ever I knew of. He said that I had been preaching against him, 
and that I had been preaching heresy. I said that was a matter for the pres- 
bytery, and not for the kirk-session. He left without receiving a token. I 
can't say whether he was offered one. My recollection is not distinct, except 
that he didn't get a token, and that the impression he was labouring under was 
entirely without foundation. Shortly after this — a few weeks probably — ^I had 
an interview with him on the Sturline road. He was working as a surfaceman. 
He stated that I was actmg under Mr Mowbray of Cambus, and had been paid 
by him to preach against him. I met him again on the Stirling road. Pris- 
oner was eating his dinner on the opposite side of the road from that on which 
I was. He crossed the road and came in before me, having in his hand a 
clasped knife open, with which he had been cutting bread. On the other arm 
he had a bottle of milk. He had a peculiar startled look. I felt in danger. 
He said that if I as a Christian minister would give him my word that I wasn't 
acting under Mr Mowbray's instructions, he would believe me. I tried to turn 
the matter off by using tne proverbial expression — the man's head's in a creel, 
saying that Mr Mowbray was the last person in the world to give any such 
instructions, and that I was about the last man to receive them from any one. 
I told him there was no chaixe against him whatever, and that if he attended 
church I knew no reason why he shouldn't receive a token at our next com- 
munion. He said nothing to that, but left me. He attended the church fw 
some Sabbaths af^er this, and, what was not very common for persons in his 
position, came to a prayer-meeting on Wednesday evening. I spoke to him at 
the close, and shook hands with him. After attending for a few Sabbaths, he 
disappeared from the church again. I saw him after tnis, on the Stirling road 
occasionally, though I rather avoided that road, being afraid of him. He had 
a very peculiar appearance, which I cannot well descrioe. I sometimes thought 
he looked like two men — ^the one face behind the other. The one face had a 
look of injury, and the other of beine superior to all his enemies. On 1 5th March 
I went to the prisoner's house, havmg first made inquiry as to the truth of the 



1864.] TRIAL OF THOMAS ARNOT FOR MURDER. 183 

report. I foand hii wife and dftoghter in ^reat difitress. I said that the general 
impreMion was that the boy had been injured by a cartwheel going over him. 
Thu was in presence of the prisoner. He said, '* Who told you that ? '* I said 
I had gathered it from information in the district. He said, '* Some person has 
done it, and you don't know the party.** I said it didn't matter as to that — I 
was only stating the general impression. He then drew himself up and said, 
" Well, sir, whoever told you that told you a lie ; for I did it." I said, "Well, 
Thomas, aren't yon sorry?" He said most emphatically, "Not a bit for the 
deed— I'm sorry for my wife and fiunily.*^ He added, " Them that have got the 
spirit may take the body also." He told me that the boy had been sent, and 
tnat this matter had been going on for twenty years, as I very well knew ; that 
the provocation he had received during all that time was such that no man 
could bear it. He said that the boy wasn't to blame, and that he had no ill 
will to the boy. I saw him next day in his own house. He again stated that 
the boy had l)een sent bv other parties ; that they should have employed some 
person of ereater mentaf capacity to do their work. He^ began to speak very 
mcoherenUy about mental force and manual labour force in connexion with the 
reformation of the world ; but that they could not accomplish it in that way, as 
the time wasn't yet come. He said that he was a poor man ; that he had never 
learnt a lesson of grammar in his life ; and it seemed very strange that there 
should be such conspiracies over the whole world against him. I think he 
said that I knew the whole matter. He said, What would they do with him ? 
This was in connexion with the reformation of the world. He asked, " If a 
man did a deed, and confessed it, would they make him insane ? " I declined 
to say. He folded his arms across his breast and said, I should think not. I 
understood the they meant his persecutors. He seemed to have no remorse ; 
but rather to think he had done something meritorious, — as if he had inflicted a 
severe blow upon his enemies unexpectedly. The prisoner was nol communi- 
cative about his delusions. I understood he was a sooer man. I never preached 
against him, nor about a man in a blue coat and with a brown bible. 

Alexander McGregor j rector of the academy at Tillicoultry, and formerly 
teacher at Tullibod^r, and an elder in Mr Goldie's congregation, proved a letter 
to be in the handwriting of the prisoner, which he had received, and in which 
the prisoner referred to a confederation against him, and certain alleged pro- 
ceedmgs of the kirk-session. 

Robert Mowbray^ distiller, Gambus. I attend the Free Church at Tullibody. 
I had no acquaintance with the prisoner. Only once spoke to him that I re- 
member of. I never gave instructions to the Kev. Mr Goldie, or to any one 
else, to annoy him. I never spoke of him to Mr Goldie that I can remember. 

Andrew Stalker j surfaceman. I work on the same road as the prisoner. My 
section of the road adjoins that on which he was employed. 1 have known 
him for about four years. He used to complain of people persecuting him. 
Mr Mowbray was one of them. He complained of the minister preaching 
against him, and that the persecutions followed him wherever he went. He 
said he had been obliged to leave home on account of these persecutions, and 
had gone to the west country. He said they had followed him there ; that 
there were paragraphs in the newspapers about him when he was away, under 
fictitious names. He gave no reason for this. He said they wanted to make 
a settlement with him, but he wouldn't take double the money. I had some 
talk with him about the Telverton case about four years ago when it was 
eoin^ on in Ireland. He asked me about it. I said it was Captain Yelverton 
denying his marriage. Says he, I'm Yelverton. That's the way they always 
do, they never mention my name. Another time we had some conversation 
about the Cardross case. He asked me about it, and then he said, I'm 
M'Millan ; and that's the way they always do. The prisoner was quite serious. 
He seemed to believe that he was the party in both of these causes. About a 
month before the murder, I had some conversation with him. I asked him 
how he was getting on with his work. He said, not very well, and that he was 
working away among mud and stones. I said we were all doing that, and what 



184 MEDICAL NEWS. [AUG. 

WAS much worse, we got little pay for our work. He said it was the Govern- 
ment did that. The Government had that in their own hands, and did what they 
liked with us. He said he could turn the Government with one hand, and he 
would make me confess that he could. He said that was a nothing, it was 
quite common. Instead of one there should be two, and instead of three, four, 
and that would break the Government. I said I believed he was <juite ri^ht. 
He said he knew he would make me confess it. He was speaking m a serious 
manner. He was a sober man. I never saw him under the influence of drink. 
I never heard of his being persecuted by any one except from himself. I 
didn't think he was right in his mind. 

Eev, ThamoB Murray, prison chaplain, deponed to several conversations he 
had with prisoner after his apprehension. On 7th May I had a long conversa- 
tion with him, fully an hour. I asked him if Mr Groldie hia minister had been 
calling for him. He answered, No. They wouldn't come near him ; It was of 
no use. He explained that he meant the Free Church. I asked what were 
the pounds of this ? He said he had been under trial for eighteen years. He 
had been employed by the Alloa Coal Company about eighteen years before ; 
that at that time the carters and others on the road had begun to annoy him 
in various ways ; hiding stones with steel in them, removing metals, etc., that 
these parties were under the leadership of Mr Lawrence Drvsdale, farmer in 
the neighbourhood. That on inquir^, he had found that Drysdale and Mr 
Hill, coal grieve, were iu communication with the Kirk Session of Tullibody, 
and that the object the Free Church had in view was to brine in the millennium. 
By this he meant a general religion in the world. He asked about a recent 
movement for general education, and said that this was just the Free Church 
movement in another form. I asked him why the Free Church should trouble 
him. He said that they had a fault with him, as his wife was not a member 
of the Free Church. He had ascertained this on seeking baptism for his 
child — but his wife had not been a member before she was married to him. 
The child was baptized, but he said the trial still went on. He told me that 
Mr Goldie was in the habit of preaching at him ; then followed conversa- 
tion as to ideas detailed by previous witnesses. The prisoner said his case 
had been before the Presbytery and the Assembly. I expressed surprise at 
this. He assured me it was quite true. I asked what all this had to do with 
the murder. He said that the boy formed part of the general system ; that 
what the boy did was a small thing, but it was his connexion with the whole 
persecutions he had suffered. He said the Free Church would now be on its 
trial, and there would be a fine' breach between it and the Government. He 
said that Scripture aUowed that he should be tried in faith, and that it also said 
that we should not be tried beyond what we could bear ; but he had been tried 
beyond what he could bear. I saw him again on 8th May. He said he under- 
stood the Free Church intended to charge him with insanity, in order that they 
themselves might escape ; that he was persecuted by the free Church for seven 
years, and that this was their plan, — if at the end of seven years he continued 
a member, he was then taken before the Presbytery — then tnere ensued a year 
of public trial, in which the Free Church was assisted by the whole community, 
and this he called the reginum donum. He said that he left the church about 
the middle of this year of public trial, but the trials were then continued to 
brinff him back to the church. I didn't think he was feigning in all this. I 
concluded he was in a state of monomania. 

Profes9or Douglas Madagan, — I have heard the evidence in this case. I 
have also seen the prisoner twice in jail, along with Dr Arthur Mitchell, on 
Wednesday and Saturday last. The result of my own observation was to con- 
sider that man as being insane. My object was to ascertain the state of his 
mind. I don't think he is fit to give instructions for his defence. Is his delu- 
sion thorough and pervasive ? Very. Affecting his views of everything that 
happens? xes; apparently so. And unfits him for taking a correct view of his 
position ? Certainly. Is that opinion confirmed by what you have heard to- 
day? Yes. His delusions are of the character described? Yes. To Um 



1864.] TRIAL OF THOMAS ARNOT FOR MURDER. 185 

(kmrt. The delusions which 70a found correspond with those described by 
the witnesses ? Tes. Examination continued, — ^And on the whole matter have 
yon any doubt of his being insane? Not the least. To the Court. — Are von 
satisfied that he is not feigning ? No, my lord ; certainly not. Have you asked 
him anything about the act ? Yes ; I spoke about the indictment, and he 
speedily got mto the delusion about the boy being an agent of the Free Church, 
and the story of his persecutions. The substance of it was, that his object was 
not to punish the boy but the Free Church. To Mr Smith, — ^Is the disease 

Eroperly described as monomania? No; I would not call it so. I say he 
kbours under mania, not monomania. 

Dr Arihur MikheU of Trinity,'—! visited the prisoner along with Dr Mac- 
lagan on two occasions, Wednesday and Saturday of last week. I came to the 
conclusion that the prisoner was msane. His delusion was general and pervad- 
ing, indicating general unsoundness of mind. He is quite unable to give 
Instructions for his defence. This opinion is strengthened by the evidence 
to-day. 

There was no evidence led on the part of the Crown to contradict this 
evidence. 

The ]x>rd Justice-General, after consultation with the other Judges (Lords 
Cowan and Deas), intimated that the^ considered this evidence sufficient to 
show that the prisoner is at present m a state of insanity,— adding fhat this 
was the judgment of the Court without any hesitation. 
The usual interlocutor was then pronounced. 



ROYAL MEDICAL AND CHIRURGICAL SOCIETY. 



ABSTRACT OF THE REPORT OF THE COMMITTEE ON CHLOROFORM. 

In laving their report before the Council of the Medical and Chirurgical Society, 
the Cfommittee on Chloroform desire to state that they have made comparatively 
little reference to the medical portion of the subject. This is not due to their 
thmking the medical uses of chloroform of little importance, but to the fact that 
but few replies to their inquiries upon this point have been received. 

In view of the great extent of the subject submitted to their consideration, 
the committee directed their attention to such points as appeared to them of 
chief practical importance. Thus, their observations respecting the action of 
chloroform on the nervous system, and their remarks on some other points, are 
less full than would have oeen desirable had the committee regarded such 
details as of equal importance with those specially elected for investigation — 
such as its influence on the action of the heart and on respiration. 

The committee have chiefly confined their physiological report to observa- 
tions which they have themselves made. Without overlooking or neglecting 
the labours of former investigators, they have endeavoured rather to furnish 
an accurate account of experiments which they have observed carefully and 
together, and to compare the results thus obtained and agreed upon with the 
phenomena of cases m which death or peril of life has arisen from the inhala- 
tion of chloroform in the human subject. 

Ph^tkHogical Condunans. — ^The sequence of the phenomena produced by 
chloroform inhalation in animals is similao to that observed in man, and if the 
Mime percentage of the agent be administered, the results produced are nearly 
uniform. The first effect of chloroform vapour is to increase the force of the 
heart's action ; but this effect is slight ana transient, for when complete an- 
SBSthesia is produced, the heart in all cases acts with less than its natural force. 
The stron^st doses of chloroform vapour, when admitted freely into the lungs, 
destroy animal life by arresting the action of the heart ; whilst by moderate 
doses the heart's action is much weakened for some time before death 
ensues, respiration generally, but not invariably, ceasing before the action 

VOL. X.— NO. 11. 2 A 



186 MEDICAL NEWS. [AUG. 

of the heart, death being dae both to the failure of the heart's action and to that 
of the respiratory ftinction. The danger attending the use of chloroform 
increases with the degree of stnpor it induces ; the apparent irregularities in the 
action of the an»sthetic mainly depending on the varying strength of the vapour 
employed, on the Quality of the chloroform, and on the constitution oi the 
patient. In order that it may be administered with comparative safety, it is 
necessary that the proportion of vapour should not exceed three and a half 
per cent. ; that its enects should be carefully watched, and the inhalation sus- 
pended when the required anaesthesia is induced. 

In many respects the action of ether is similar to that of dilute chloroform. 
At first its vapour increases the force of the hearths action — an effect which is 
both greater and of loneer duration than that observed with chloroform. The 
stimulation is followed by a depression of the force of the heart's action, but at 
the same degree of insensibility ether does not depress the action of the heart 
to the same extent as chloroform. Eventually, ether kills partly by enfeebling 
the action of the heart, but chiefly by arresting the movements of respiration. 
Thus the energy with which chloroform acts, and the extent to which it 
depresses the force of the heart's action, render it necessary to exercise great 
caution in its administration, and suegest the expediency of searching for other 
less objectionable annsthetics. Ether is slow and uncertain in its action, 
thoi^h it is capable of producing the requisite insensibility, and is less danger- 
ous in its operation than chloroform. On the whole, however, the committee 
concur in the general opinion which in this country has led to the disuse of 
ether as an inconvenient anaesthetic. 

A mixture of ether and chloroform is as effective as pure chloroform, and a 
safer agent when deep and prolonged ansesthesia is to be induced ; though slow 
in its action, it is sufficiently rapid in its operation to be convenient for general 
use. A mixture composed of three parts of ether, two parts of chloroform, and 
one part of alcohol (by measure), is to be preferred on account of the uniform 
blending of the ether and chloroform when combined with alcohol, and the 
equable escape of the constituents in vapour ; and the committee suggest that 
it should be more extensively tried than it has hitherto been in this country. 

Effects of Chloroform on the Fauces, — The sudden administration by the mouth 
of concentrated chloroform vapour induces a spasm of the fauces which lasts 
for some seconds ; afterwards, when the animal has inspired, the phenomena of 
asphyxia are for a time associated with those of chloroform poisoning, and 
death is finally induced as by dilute chloroform. If, however, partial insensi- 
bility is first induced b^ weaker chloroform, no spasm of the fauces ensues upon 
the sudden administration of the concentrated form of the agent. 

Post-mortem Appectrances. — Judging from the observations on animals,— the 
appearances in the human subject having been noticed in but few cases, and 
bemg insufficient for yielding satisfactory conclusions, — it appears that though 
there may in certain cases be an impediment to the free circulation of the blood 
through the lungs, yet the appearances are very different after death has been 
caused by chloroform from tnose observed when life has been destroyed by 
asphyxia. In death from chloroform, all the cavities of the heart are distended, 
and the cases are only exceptional in which the left side is empty. The rule, 
however, is alike in both : that the cavities of the right side contam more blood 
than those of the left. 

BesuscittUion.-~-The most certain means of restoring life after poisoning with 
anaesthetics is by artificial respiration. By this means resuscitation may 
generally be accomplished after natural respiration has ceased, provided the 
heart continues to act, and it may sometimes be effected even after the cessation 
of the heart's action ; but this result is exceptional. Galvanism resuscitates 
within the same limits as artificial respiration ; it is, however, fkr less to be 
relied on than artificial respiration in equal cases. With either remedy it is 
found that animals quickly rendered insensible by a strong dose are more 
easily recovered than those which have been gradually narcotized even by a 
•mall percentage of the anaesthetic. 



1864.J REPORT ON THE ACTIONS OF CHLOROFORM. 187 

Rules rdaUng to Ae AdnUmgiratum of Chhroform. 

The anaofithetic should on no accoant be given carelessly, or by the inex- 
perienced; and when complete insensibility is desired, the attention of its 
administrator should be exclusively confinea to the duty he has undertaken. 

Under no circumstances is it desirable for a person to give chloroform to 
himself. 

It is not advisable to ^ve an anesthetic after a long fast, or soon after a 
meal ; the best time for its administration being three or four hours after food 
has been taken. 

If the patient is much depressed, there is no objection to his taking a small 
quantity of brandy, wine, or ammonia, before commencing the inhalation. 

Provision for the free admission of air during the patient*s narcotism is abso- 
lutely necessary. 

The recumbent position of the patient is preferable ; the prone position is 
inconvenient to the administrator, but entails no extra danger. In tne erect or 
sitting posture there is danser from syncope. Sudden elevation or turning of 
the body should be avoided. 

An apparatus is not essential to safety if due care be taken in giving the 
chloroform. Free admixture of air with the anesthetic is of the first importance, 
and, guaranteeing this, any apparatus may be employed. If lint, or a handker- 
chief, or a napkin Lb used, it should be folded as an open cone, or held an inch 
or an inch and a half from the face. 

The anaesthetic should invariably be given slowly. Sudden increase of the 
strength of the anaesthetic is most dangerous. TKree and a half per cent, is 
the average amount, and four and a halfper cent, with ninety-five and a half of 
atmospheric air is the maximum of the anaesthetic which can be required. 
Given cautiously at first, the ^uantit^, within this limit, should be slowly 
increased accordmg to the necessities of'^tiie case, the administrator being guided 
more by it^ effect on the patient than by the amount exhibited. 

The administrator should watch the respiration of his patient, and should 
keep one hand free for careful observation of the pulse. 

The patient who appears likely to vomit whilst beginning to inhale the an- 
SBSthetic should be at once brought fully under its influence, and the tendency 
to sickness will then cease. 

The occurrence during the administration of an ansesthetic of sudden pallor 
or of sudden lividity of the patient^s countenance, or sudden failure or flicker- 
ing of the pulse, or feeble or shallow respirations, indicates danger, and neces- 
sitates immediate withdrawal of the anaesthetic until such symptoms have 
disappeared. On the occurrence of these symptoms, and especially if they 
should become so urgent as to threaten death from failure of respiration, of 
heart-action, or of both together, the following rules of treatment are to be 
observed : — Allow free access of fresh air ; puU forward the tongue, and clear 
the month and fauces ; keep or place the patient recumbent ; dMh cold water 
on the face and chest, and aid the respiratory movements by rhy^thmical com- 
pression of the thorax. In the more threatening cases artificial respiration 
must be commenced instantly ; and this rule applies equally in all cases, whether 
the respiration has failed alone, or the pulse and respiration together. Gal- 
vanism may be used in addition to artificial respiration, but the artificial 
respiration is on no account to be delayed or suspended in order that galvanism 
may be tried. 

Few if any persons are unsusceptible of the influence of chloroform, from two 
to ten minutes being required to induce anaesthesia. The time, however, varies 
with age, temperament, and habits. 

The mixture of chloroform, ether, and alcohol should be given in the same 
way as chloroform alone ; care being taken, when lint or a handkerchief is used, 
to prevent the too free escape of the vapour. 

Use of Chloroform in Surgical OperatUme. 
With heart disease the anaesthetic may be given in any case which requires 



188 MEDICAL NEWS. [AUG. 

an operation, although when there iseyidence of a fatty, weak, or dilated heart, 
great caution is demanded. Valvular disease is of less importance. 

In phthisis, when an operation is unavoidable, the anaesthetic may be given 
with impunity. 

For all operations upon the jaws and teeth, the lips, cheeks, and tongue, the 
anaesthetic may be inhaled with ordinary safety. By care and good manage- 
ment the patient may be kept under its influence to the completion of the 
operation. In these cases, mood, as it escapes, if not voided by the mouth, 
passes into the pharynx. If any small quantity finds its way through the 
urynx, it is readily expelled by coughing. In operations upon the soft palate, 
fauces, pharynx, and posterior nares, if sudden or severe hsemorrhage is likely 
to occur, it IS not advisable to induce deep insensibility. 

In cases requiring laryngotomy and tracheotomy the ansssthetic may be em- 
ployed with safety and advanta^. 

For operations upon the e}re, involving the contents of the ^lobe, the use of 
annsthetics is open to objection on account of the damage which the eye ma^ 
sustain from muscular straining or vomiting. If employed, profound insensi- 
bility should be mduced. 

In operations for hernia, and in the application of the taxb, the ansesthetic 
acts most beneficially. For most operations about the anus profound anaesthesia 
is positively demanded. 

In the condition of shock, or of great depression, aa after haemorrhage, care- 
ful administration of the anaesthetic diminishes the risk of an operation. 

In all cases, other than those specially referred to, it is sufficient to state, so 
far as a mere surgical operation is concerned, that an anaesthetic may invariably 
be administered. 

The continuous vomiting occasionally induced by and foUowin^ upon the 
inhalation of anaesthetics, may be injurious by consequent exhaustion, as well 
as by mechanically disturbing the repair of a wound. With this reservation, 
they do not appear to interfere with the recovery of patients from surgical 
operations. 

Statigtie8,—'The results of 2586 capital operations performed before, and of 
1860 performed since, the introduction of anaesthetics, collected from aXL 
authentic available sources,^ prove that anaesthetics have in no degree increased 
the rate of mortality. 

Use of ChJorofarm in ObsUtric PtacUce. 

(a) In Natural Labour, — ^The careful administration of chloroform during 
labour is not attended with special danger, there beins, either in this country 
or abroad, so far as is known to this committee, no well-authenticated instance 
of sudden death where it has been given by a medical practitioner ; but the 
occasional occurrence of un&vourable symptoms demands the exercise of cau- 
tion during its employment. Administered in a moderate degree, it does not, 
as a rule, weaken the expulsive powers, and is decidedly beneficiad in promoting 
dilatation of the maternal passa^. It does not predispose to puerperal con- 
vulsions or other like complications. The balance of opinion is nearly equal as 
to whether it predisposes to imperfect contraction of the uterus after delivery. 
As a rule, it in no way retards the convalescence of the mother ; nor has it any 
tendency to interfere iinuriously with the function of hictation ; nor has it any 
injurious influence on the child. 

{b) In Abnormal Labour, — ^The anaesthetic may be employed with advantage 
in various obstetrical operations — as forceps, turning, craniotomy, and extrac- 
tion of retained placenta, — unless the patient is much enfeebled by haemorrhage ; 
when, if given, it ought to be accompanied by the use of stimulants. It may 
also be employed advantageously to check the paroxysms in puerperal con- 
vulsions. 

(c) At to the prtference of ether. Ruka relating to the administration of 

1 Appendix D Co the Beport, p. 148. 



1864.] BEPOBT ON THE ACTIONS OF CHLOROFORM. 189 

cyor^/brm.— There are no reasons for giving preference to ether over chloro- 
form, the latter being much more desirable in obstetrical practice generally, 
the only exceptions being those in which chloroform notably disagrees. 
In addition to those given for its administration in ordinary cases, it is 

gmerally desirable to observe the following rules during its administration in 
bour, subject to modifications at the discretion of the practitioner: — In 
natural labour, b^in to give it generally at or after the termination of the first 
stage ; but it may he given earlier if the first stage is unduly painful, or if the os 
uteri resists dilatation. Give it only during the pains, and withdraw it in the 
intervals. When the foetal head bears on the perineum, give it more freely to 
promote relaxation and relieve the increased pain. Withdraw the chlorou>rm 
unmediately after the child is ex^lled. If the patient is depressed or the 
pains are sluggish during its admmistration, an occasional stimulant mav be 
adroinbtered. In cases where it seems to interfere with the progress of laoour 
it may be necessary to suspend its use for a time, and reappljr it after an 
interval, or even to withdraw it altogether. In turning and instrumental 
deliveries deep anaesthesia must be induced, as in surgical operations, and the 
administration should then be intrusted to a competent person, whose sole 
duty should be to attend to it. In midwifery a special inhsier for its adminis- 
tration Lb not generally necessarv or desirable, a handkerchief or towel, so 
folded as to prevent blistering of tne face and to allow free acimixture of atmos- 
pheric air, being sufficient for the purpose. 

(d) Uae of Chhrqfarm in Diaeatea of Women and Children, — ^In the treatment 
of diseases of women, chloroform may be employed to facilitate and lessen the 
pam of certain examinations. In cases of spurious pregnancy and phantom 
tumours, by relaxing the abdominal parietes, it may assist in demonstrating 
their true characters ; and, acting in the same wa^r, it may help the practitioner 
to define more accurately the character and relations of other abdominal and 
pelvic tumours, or to detect feigned disease. 

As a therapeutic agent, its inhalation and external application in the form of 
a liniment, may be usefiUly employed to allay pain in some cases of severe 
dysmenorrhoea, neuralgia, and the like. 

There is accumulated testimony in favour of cliloroform inhalation proving 
serviceable in various spasmodic diseases of women and children ; as whooping- 
cough complicated with convulsions, spasmodic croup, epileptic seizures, and 
some other forms of convulsion in children ; hysterical convulsions, epilepsy, 
and various muscular contractions in women. 

The President expressed in warm terms the obligations the Society were 
under to the committee for their able and laborious report. 

Mr CurUng regretted that so much time had elapsed since the committee 
had been formed. But, as would appear when the paper and the appendix 
were published, much more work had been done than would be thought from 
the part of the abstract which had been read. There had been a division of 
labour into three chief departments : physiological, surgical, and obstetricaL 
But the most work had been done by the first section — ^the physiological. 
This section had had seventy meetings, and had performed very many careful 
experiments. When all this was taken into consideration, the Fellows would 
not be surprised that the report had been delayed. The committee wished to 
acknowledge the support afforded by many Fellows of the Society and bv the 
profession generally. Mr Curling said that he must allude more pointedly to 
the labours of the reporters, Mr Sibley and Mr Callender. These gentlemen 
had attended all the meetings of the committee, and it was, after hearing the 
report, scarcely necessary to express any opinion as to the great zeal, devotion, 
and intelligence they had displayed. 

Dr Kicld said a great debt of gratitude was due to Mr Curling and the 
Physiological Committee for their incessant labours ; yet he could not help 
thinking the great chloroform question at present was, as to its safety or 
use, a question of practical or empirical observation in hospitals rather than a 
question of physiology. Nobody denied that very laige doses killed animals. 



190 MEDICAL NEWS. [AUO 

We had similar experiments in vast number in books, but the deaths in 
practice in the human subject are from idiosyncrac^ (from which the lower 
animals are free), from errors of administration, emotion, fright, in the convul- 
sive or preliminary stage before deep anaesthesia at all, deaths from spasm of 
the glottis, apnoea, almost always m trivial operations, like tooth-orawing, 
rather than in the half-hour's deep narcotism of large operations. Physiolo- 
gical experiments, such as dropping chloroform on the heart of a frog, or 
throwing it into the peritoneum, are fallacious ; the experiment kills, but not the 
cMoroform. Then, as to " mixtures " of anaesthetics, they have been used exten- 
sivelv in Austria and France, even bv order of Government. The ether was 
founa to be first inhaled, then the chloroform, and the spirit of wine remains 
behind and has to be squeezed out : they tend towards mystery and are cum- 
bersome. The best part of the report is as to the value of electro-magnetism 
in resuscitation ; but it is an error that the little magnet-box is not accessible 
in hospitals. It is equivalent to saying saving life is not important. The mid- 
wifery portion of the report does not offer much that is new, and so of the 
general sur^rv part ; but both are good. But as to the use of chloroform in 
medicine it is aencient, as this agent is most valuable in asthma, pain of gall- 
stones, tetanus, convulsions of children, whooping-cough, and a dozen other 
affections. There is at surgical operations now less arterial but more vexlons 
blood than formerly : even vomiting will fill a wound with blood (secondary). 
Chloroform is safe m what is termed shock or collapse. This is the *' law of 
tolerance " so well described bv Miller ; but sur^ons do not read of empirical 
rules so much as physiological experiments. The speaker fully agreed as to 
the CTeat value of artificial respiration in accidents, out that was best set up 
by the electro-magnetism box, as now extensively tried. It is true also that 
resuscitation is more difficult in ether accident cases than from chloroform. 

Dr Hyde Salter said a point had been overlooked, but on which it was not 
possible for the committee to have investigated in so short a time as they had 
taken for their report. It was as to the effect on the human constitution of 
chloroform administered for months or for vears. He offered this as a sugges- 
tion for further investigation. Dr Salter then related the case of a gentleman 
who for three years had taken chloroform nearly every night. The effects 
were somewhat like those of alcohol : general loss of nervous power, insomnia, 
and vomiting in the morning. The chloroform was taken for asthma, and 
sometimes as much as three ounces were inhaled in one night. The effect waa 
most distressing. The patient lost appetite, became morose, and was unable 
to sleep. He tor one month was able to avoid it, and the improvement was 
most marked. He got to sleep earlier and earlier every night. This, however, 
the patient ascribed to Indian hemp which he took at the time; but on taking 
the chloroform a^in, he again haa insomnia, and Indian hemp failed to help 
him. The vomitmg in the morning was like that of drunkards. Dr Salter 
considered that in other respects the effects would be found to resemble those 
of alcohol. 

Mr Savory asked under what circumstances and to what extent, in collapse 
from injuries or from hsemorrha^, chloroform might be administered. It was 
true that it would tend to diminish shock ; but it would, on the other hand, be 
likely to render the pulse almost imperceptible. It was a point of great 
interest that chloroform tended to reduce the temperature, even, as some 
experiments showed, seven or eight degrees. In collapse, too, the temperature 
was diminished ; and hence, if chloroform were given, there would be two con- 
ditions tending to the same result. 

Dr C, J. B. Williams said there could be but one opinion as to the great 
debt the Societv owed to the committee— a debt which the Society was 
scarcely able fully to appreciate until the publication of the report. One 
important point was, however, settled : that chloroform depressed the action of 
the heart. This was an important result, as it had been much disputed. It 
accorded with the results of experiments he himself had performeo ; and the 
histories of cases of death from chloroform all converged to the same point. This 



1864.] REPORT ON THE ACTIONS OF CHLOROFORM. 191 

in itself helped to suggest methods of coantemcting the effect of too Uirge a 
dose. One obvious method was to add ether and alcohol to the chloroform. 
Bat there was no reason why alcohol, ammonia, or any other stimulant, should 
not be given by the mouth. O^gen had been su^ested, and had, it was said, 
been xk^d in America with success : and it was not miprobable that chloroform 
and oxygen might form a useful and safe combination. One class of anaes- 
thetics Uid not been alluded to— namely, nitrous oxide. From his own obser- 
▼ations some years ago, it appeared to be not so depressing, and it was safe. But 
there were dmculties in procuring it, and in applying it. Dr Williams then 
aJAuded to the effect of chloroform on the blood, and asked what researches the 
committee had made in this part of the subject. 

Dr Kidd observed that two deaths were published this year from nitrous 
oxide used as an anesthetic, so that it is not nree from accident, as Dr Williams 
might have supposed. As to the use of a little brandy or ammonia before 
administration, the plan was a good one, and always adopted by himself. Then 
as to the blood, it was perfectly known, from hundreds of experiments, that 
chloroform does not disturb its character at all. But it was not so with ether ; 
here the corpuscles are destroyed, and the ether was so dissolved in the blood 
tliat it had l^en distilled over and over again from the blood of an animal 
deeply narcotized by it. Crystals were of less moment in blood long drawn. 
Forty-one deaths from ether had been publbhed in America, and nineteen by 
Trousseau in France. It seemed paradoxical that chloroform administered in 
small doses should be daneerous. But it was small doses which produced con- 
vulsive vomiting ; and so death in hospitals began as a sort of spasm or con- 
vulsive irritation of the fauces and glottis, while the patient was half conscious, 
not in deep coma ; with a sort of reflex or tetanic rigidity of the respiratory 
muscles ; the heart still beating actively, till overpowered or engorgea at the 
right side. Hence the great value of artificial respiration. The breathing, in 
fact, stopped ; and yet the patient did not inhale the large percentages given 
to animals, the chloroform at boiling-point in balloons, etc. It seemed para- 
doxical to deny physiological experiments, but we did not prevent glaucoma or 
ague by physiology, but rather hy empirical rules ; so was it with regard to 
chloroform and prevention of accidents. Oxypen, too, had been tried, but 
found wanting: the blood was not deoxygenized, at least by chloroform. 
Anesthesia was like hvbernation. The blood would not ti^e up pure oxygen. 
In a case at a borough hospital where oxygen was accurately tried it proved 
useless. There was a fear that students trusted too much to a complex appa- 
ratus. They did not detect the danger early enough. To them " mixtures " 
like those of the new Pharmacopoeia would be a sort of mitigation of danger, — 
a kind of drag to the wheel of antesthetic progress. Nor did the heart first 
stand still, as supposed by some ; it was a popmar error. While as to nitrous 
oxide, and even ether, they were both now given up in America, where they 
had been extensively administered. 

Dr Wynn WiUiams recommended that in collapse from chloroform warm 
port-wuie should be injected by an 0*Beime*s tuoe. He had tried this in 
collapses from other causes, and had found it to act energetically. It seemed, 
he thought, by increasing the warmth, and by giving a stimulant at the same 
time, to meet Mr Savory"s remarks. 

Dr Ballard objected to that part of the report in which the use of chloro- 
form in the convulsion of children was recommended. He was satisfied that 
it had no beneficial effect, and asked if its use had been recommended after a 
trial in cases. 

Mr Curling said it was not recommended that chloroform should be given 
until reaction set in after injuries, but then it acted beneficially in the operation 
by diminishing shock. In reply to Dr Ballard he said that the recommenda- 
tions of the committee were based on a series of facts, and after a krge 
experience. 

Dr Barley said the action of chloroform on the corpuscles was but slight, 
but if ether were added, it dissolved the walls of the corpuscles. It had been 



192 MEDICAL NEWS. [aUG. 

lone observed by Dr Jackson of New York, that chloroform produced formic 
add in the ii;^stem ; but it was impossible to trace the changes. If blood were 
shaken up with ether it would sometimes crystallize. Diseased blood would 
also sometimes crystallize spontaneously, while blood after slow death from 
chloroform, when shaken up with ether, always became like a mass of crystals. 

(Dr UatUy then introduced to the notice of the Society an inhaler sent to 
him by Dr Skinner of Liverpool, and also an ingenious apparatus, invented by 
Dr Squire, for measuring accurately the percentage of chloroform.) 

Dr Pearwn said he was surprised to hnd that chloroform was more feared 
here than in Edinbursh, where it was invented. In Edinburgh apparatus was 
altogether disregarded. He felt certain that it was safer to give chloroform 
without an inhaler than with one. 

Dr Hyde Salter said that chloroform mieht be given so as to prevent pain 
and yet not produce insensibility ; for this he could vouch, as he had experi- 
enced it himself. If, then, it could be discovered how to do this, it wouldT not 
only lessen the risk, but would diminish the fear of the use of the drug. 

Jjr Wright said that the inhaler had been used a year in Mr Spencer Wells* 
ovariotomy operations, but it was liable to the objection that a good deal of the 
chloroform escaped, and thus affected the bystanders. 

Mr BirkeUy one of the honorary secretaries, said that it had been impossible 
for him to read the whole of the ^stract, but he had only omitted those parts 
which the reporters had agreed should be omitted. — The Lancet. 



NOTE ON A CASE OP POISONING BY THE CALABAR BEAN 

{Phywstigma Venenaaum). 

By David Young, Medical Missionary Dispensary, Edinburgh. 

Although the following case does not add much to what is already known 
regarding the action of this poisonous bean, still, considering the limited num- 
ber of cases that have been recorded touching its influence upon the natives of 
this and other European countries, it may not be without interest. The facts 
of the case are the following :— - 

In the month of April last, a few of the beans came into the possession of a 
cabinetmaker, who supposed them to be a peculiar kind of nuts. On the 13th 
of June, three or four of them fell into the hands of two children, named David 
Wales, aged six years, and James Greig, aged three years. At seven o'clock on 
the evening of that day, both the children were observed by their parents to 
be amusing themselves with the " nuts." About twenty minutes past seven 
the children disappeared, and in twenty minutes from that time they both re- 
turned to their respective homes, complaining of sickness. The mother of 
James Greig sUtes, that at a quarter before eight o'clock her child entered the 
house, his head drooping listlessly, his eyes sleepy-like, and his hands power- 
less. On entering the room, he staggered against the door, and was scarcely 
able to walk towards her. She took him upon her knee, and questioned him 
as to the cause of his peculiar appearance. Her attention had been previously 
drawn to the " nuts," which she suspected were poisonous ; and on asking the 
child if he had eaten any of them, he confessed that he had. He complained 
of severe pain in the epigastric region, made ineilectual efforts to vomit, and 
begged that he might be laid upon his bed. He requested also to be allowed 
to sleep, and drew up his legs, as if to relieve pain. When ho had been in the 
house about fifteen minutes, half a pint of milk was given to him, which 
he drank eagerly. In from five to ten minutes after the milk was swallowed, 



186i.] NOTB OF A CASE OF POISONINQ BT THE CALABAB BEAK. 183 

free vomiting enaoed, the vomited matter appearing to conaiat entirely of 
curdled milk. The mother did not observe any pieces of the ** not^** hot she 
did not examine carefully. The vomited matter was removed and thrown out. 
Immediately after this the child was taken out of the house, for the benefit of 
fresh air, but he cried to bo taken back to bed. At a quarter before nine, the 
mother came to the Dispensary. A small dose of ipecacuan wine was ad- 
ministered, which was repeated in fifteen minutes. In about ten minutes after 
this the case was fint seen by me. 

I found the child lying in bed, his pnpils were slightly contracted, his pulse 
feeble and slow, and he appeared to be totally prostrated. As he had not 
vomited after the administration of the ipecacuan wine, and as there was a 
supply of this emetic at hand, I immediately gave him a small dessertspoonful 
in Inke-warm water. This was followed, in fifteen minutes, by copious vomiting. 
I carefully examined the vomited matters, and found four pieces of the *' nut " 
which the child had eaten. 

David Wales returned home at the same time as Greig. His father stated 
that his eyes were " working,^* or, as his mother said, " as if the nerves were 
upon him.^* He complained of severe pain in the umbilical region ; he looked 
sleepy, Ustless, and depressed, and begged to be put to bed. In a few minutes 
after he was Uid upon the bed, copious vomiting ensued. He was so feeble 
as to be unable completely to eject the vomited matter, and a neighbour, on 
putting her finger into his mouth, removed four or five pieces of the '* nut.'* 
He then requested to be taken to the closetf but he could neither stand nor 
walk, and when carried by his father and placed upon the seat, he required the 
constant support of his arm. He was freely purged. At this stage I saw the 
child, whose face was pale, his eyes heavy, and his pupils and pulse natural. 

On the following day the children complained of sickness, and declined their 
food. On the third day they were quite well. 

Wales, when subsequently questioned, admitted that he had broken two of 
the nuts by means of a poker; that each nut was broken into about five pieces ; 
and that Greig and he had each eaten the broken fragments of one nut. He 
did not chew the pieces, but swallowed them whole. When shown seven 
similar mOs, and asked to select one of about the size of those he had broken, 
he pointed to one an inch in length and half an inch in thickness, weighing 
65 grains. 

I secured a few of the beans, which, on being shown to Dr Burns Thomson 
and other competent judges, were declared to be true specimens of the 
Physostigroa venenosum or Calabar Bean. 

The reason why the symptoms in these cases were not more fully developed, 
and that they did not end fatally, considering the quantity of the poison taken, 
is so be found in the circumstance that the beans were not finely divided, and 
that they were ejected before they had been fully operated upon by the gastric 
juice. 

MEDICAL PRACTITIONERS IN MELBOURNE. 

The Medical Register for 1864 is at last published, just five months after date. 
It contains the names of those who, in answer to a circular issued by the Medical 
Board, forwarded their names, addresseb, and qualifications. Of these there are 
407 qualified, 6 transferred from the old register, and 7 certificated by the board, 
as practising under sufferance. It therefore appears that, taking the population 
of this colony at 500,000, there is one medical adviser t6 every 12M) persons. 
VOL. X.— NO. II. 2 B 



194 



PUBLICATIONS AND PERIODICALS RECEIVED. [AUG. 1864. 



In England there is one to every 1712 personn, a high numerical difference, 
for or againdt this colony, as it may be considered. Many, however, have not 
registered, thinking the act a failure, as it certainly in many ways is. It is, 
however, most liberal, including all sorts of universities and pseudo-universities, 
homoeo-quackish colleges, unqualified men, and men showing no stated qualifi- 
cation, making the possession of a legal status one of very dubious honour. 
There are also severau men registered, residents of neighbouring colonies, an un- 
warranted stretch of the act. Of the class of qualifications it may be observed 
that there is not one single M.D. of either London, Cambridge, Oxford, or 
Dublin, holders of that degree invariably hailing from universities not granting 
the de^ee of M.B. This proves what has often been affirmed relative to the 
little likelihood of M.B.V returning for the full degree except when remaining 
in practice in the immediate vicinity of their alma maier. In reckoning the 
number of medical men those pests, counter prescribers, are not included, yet 
most of them have nearly as much right to be there as many who have had 
the privilege extended to them, and their pernicious influence perhaps not 
greater. — Melbourne Medical and Surgical Review, 

PUBLICATIONS RECEIVED. 



Bell, — Practical Observations on Diphtheria 

and Erysipelas. By Charles Bell, M.D. 

London, 1864. 
Braithwaite,— The Retrospect of Medicine. 

By W. & J. Braithwaite, M.D. January 

to Jane 1864. London. 
Bimifitead,— The Pathology and Treatment 

of Venereal DiHeases. By Freeman J. 

Bamstead. New Edition. Philadelphia, 

1864. 
Comer, — Treatment of (Consumption. By 

Matthew Corner, M.D. London, 1864. 
Duncan, — V'ariations of the Fertility and 

Fecundity of Women according to Age. 

By J. Matthews Duncan, M.D. Edinburgh, 

1864. 
Hicks,— Combined External and Internal 

Version. By J. B. Hicks, M.D., etc. 

London, 1864. 
Hodge, — The Principles and Practice of Ob- 
stetrics. By Hugh L. Hodge, M.D. Phila- 
delphia, 1864. 
Jago, — Entoptics, with its uses in Physiology 

and Medicine. By James Jago, M.D. 

London, 1864. 
Medical Officers of the Army, the Case of, 

fairly stated. London, 1864. 



M^decine et de Chirurgie pratif^nes, Nouveau 
Dictionnaire de. Tome Premier : premi^ 
partie. Paris, 1864. 

Peet, — The Principles and Practice of Medi- 
cine, designed chiefly for Students of Indian 
Medical Colleges, hy John Peet, M.D. 
London and Bombay, 1864. 

Pereira, — Selections rrom Physicians* Pre- 
scriptions. By Jonatlian Pereira, M.D. 
Fourteenth Edition. London, 1864. 

Puraell,— Exanthematous Diseases : their 
Rational Pathology and Successful Treat- 
ment By John Pursell, M.D., etc. Lon- 
don, 1864. 

Ranking and Radcliffe,— Half- Yearly Ab- 
stract of the Medical Sciences. Edited by 
W. H. Ranking, M.D., and C. B. Radcliffe, 
M.D. January to June 1864. London. 

Sonnenkalb, — Anilin und Anilinfarben in 
toxikologischer und medicinal polizeilioher 
Beziehung. Yon ProC Dr Sonnenkalb. 
l^ipzig, 1864. 

Weekly Return of Births and Deaths in the 
City of Dublin in 1864. 

Williamsoo,— Thoughts on Insanity and its 
Causes. By W. Wil.iamson. Second 
Edition. London, 1864. 



PERIODICALS RECEIVED. 



American Journal of the Medical Sciences, — 
April. PhiUideluhia, 1864. 

Births, Deaths, ana Marriages, Monthly Re- 
turns of, for May and June 1864. 

British and Foreign Medico-Chirurgical Re- 
view, — July. London, 1864. 

British Medical Journal, — June 4, 11, 18, 
25; July 2, 9, 16,23, 1864. 

Bulletin (J^n^rale de Th^peutique, — June 
15, 30, 1864. 

Dublin Medical Press,— June 1, 8, 15, 22, 
29; July 6, 13,20, 1864. 

Gazette des Hopitanx,— Nos. 61 to 83. Paris, 
1864. 

Gazette Hebdomadaire de M^decine, etc. — 
June 3, 10, 17, 24 ; J uly 1, 8, 15, 22. Paris, 

" 1864. 

Gazette M<Cdicale d'Orient, — April, May. 
Constantinople, 1864. 



Gazette M^dicale de Paris,— Nos. 22 to 30, 

1864. 
Glasgow Medical Jouma],~Jnly 1864. 
Journal de M^ecine et de Chirurgie, — 

June and July 1864. 
Journal ftir Kinderkrankheiten,>-March and 

April. Erlangen, 1864. 
Journal of Mental Science,— J uly 1864. 
Medical Times and Gazette,— June 4, 11, 18, 

25; July 2, 9, 16, 23, 1864. 
Ophthalmic Review,— No. 2. July 1864. 
Revue de Th^rapeutique Mrdico-Chirur|^i- 

cale, — June 1, 15: July 1, 15. Paris, 

1864. 
Vierteljahrschrift fiir die praktische Heil- 

kunde,— Vol. 2. Prague, 1864. 
Virchow's Arch iv,— Vol. 29. Berlin, 1864. 
W Urzburger Medicinsche Zeitschrift, — Vol. 

5: PartL 1864. 



^avt iFtv0t 



ORIGINAL COMMUNICATIONS. 

Abticle I. — On the Treatment of AUmminuria in Children. By 
Wm. H. Dickinson, M.D. Cantab., Asaistant-Physician to the 
Hospital for Sick Children. London, and Curator of the Patho- 
logical Museum, St George s Hospital. 

Only one of the forms of disease which are known as the source of 
albuminuria ever occurs in childhood. 

The granular kidney is almost unknown before the age of twenty. 
The only state of disease to which the substance of the kidney is 
liable during childhood, is that which gives increase of bulk, with 
a smooth mottled exterior. I need not repeat what has been else* 
where urged, that the fundamental change in all such cases is an 
inflammatory state of the tubules, in consequence of which they 
become choked up by ap excess of their own epithelial growth. 
The accumulation is favoured by the contortion of tne tubes. When 
these channels are enabled to discharge their contents, the disease 
will soon be at an end. 

The mechanical obstruction of the tubes is the only event to be 
feared. If the complaint proves fatal, it is in consequence of this 
occurrence. It is this which interferes with the formation of urine, 
occasions the accumulation of its components in the blood, and is 
the source of all the evils to which ttie victims of the disease are 
liable. It must be the aim of treatment to keep the tubes clear ; 
this done^ the disorder will right itself. The increased vascularity 
will subside when free secretion is possible ; and, if nothing is done 
to keep up the irritation of the gland, the catarrh will soon be at 
an end. 

We must seek then to increase the quantity of fluid which washes 
the tubes, without doing anything which can produce local irritation. 
In short, we must pass as much toater as possible through the 
organ. This fluid is necessarily devoid of irritating qualities. It 
probably makes no demand upon the true secreting power of the 
gland, but passes b^ filtration m>m the Malpighian bodies. 

I have aaopted^ since the year 1860, a plan of treatment founded 
upon these principles : and when appliecl to children, the results 
have been such tnat 1 have determined to bring them before the 
Profession. 

VOL. X.— no. in. 2 c 



196 DR DICKINSON ON THE TREATMENT OF [SEPT, 

The tendency of medical observers to find success in methods of 
treatment devised by themselves, is an influence probably more 
constant in its operation than any remedy to which suffering 
humanity is subjected. The consciousness of this source of error 
has made me very cautious in drawing conclusions upon this ques- 
tion, and has induced me to resort to what means I could of testing 
the results. 

The treatment of the disease in grown persons does not enter into 
consideration here. The tardiness with which the adult kidneys 
respond to stimuli, makes a modification of the svstem necessary. 

With children the method has been mainly hydropathic. The 
way it has been carried out, and the results which have been 
attained, will appear from the following details. 

Every case of albuminuria in children which I have had to treat 
since October 1860, has been subjected to the same regimen, 
though in some cases the dropsy was so great as to seem to prohibit 
fluids. Notes have been kept of twenty-six cases, most of which 
were severe. Many others, of less import, have come and gone 
amonff out-patients, and left no record. All have been restricted to 
a fluid diet, which nas been of a nutritious character. Besides this, 
a certain quantity of spring water, varying firom two to four pints, 
has been administered in the twenty-four hours. In three of the 
cases no other remedy was used. In the remainder the action of 
the water has been seconded by small doses of infusion of digitalis, 
or more rarely of acetate of potass. Lastly, when the active 
svmptoms have disappeared, iron has been given, either as sesqui- 
chloride or acetate. 

The results may be stated generally. Of the twenty-six cases 
thus treated, twenty-two were known to have recovered and to have 

fot rid of every trace of albumen. Three improved greatly, and 
ad little evidence of disease excepting slightly albuminous urine, 
when they ceased to attend the nospital and were lost sight of. 
The remaining case ceased to be my patient, and, as I learned, 
eventually died. Thus, out of twenty-six cases twenty-five are 
believed to have recovered, which result is known to have been 
completed in twenty-two. Many of the cases were of the greatest 
severity, such that before the adoption of this system of treatment 
no expectation would have been held of their recovery. 

These results do not suffer by comparison with those attained by 
other methods of treatment. 

In the Hospital for Sick Children, I have been able to collect the 
particulars of thirty-nine cases which were admitted as in-patients 
oetween the years 1852 and 1861. Of these, twenty are known to 
have recovered. Eleven died, while eight were more or less relieved. 
The remedies for the most part were aperients and diaphoretics, the 
latter including vapour baths and antimony. It must oe considered, 
however, that from the inadequate size of this institution, none but 
very severe cases can be admitted ; and, therefore, no equal com- 



1864.] ALBUMINURIA IN CHILDREN. 197 

pariBon can be made between these results and those derived from 
more mixed cases. 

Dr Miller, in his work on scarlatinal dropsy, states, that of 
sixty-nine cases afforded by dispensary practice, eight died. His 
treatment was that in vogne ten or fifteen years ago, by bleeding, 
purging, and sweating. 

It was fomid that with the cases under consideration the number 
of days under treatment, before the patient was restored to apparent 
health, varied from ninety-seven to four j the average of the whole 
numb^ of cases being thirty. A certam time was then required 
to get rid of the last traces of albumen. The recovery was thus 
delayed to between 179 and seven days, giving an average of forty- 
five days from the commencement of treatment to the total disap** 
pearance of the albumen. 

It was found that the use of the water when given under the 
circumstances stated, never increased the dropsy, but the contrary. 
It was usuid, however, when the oedema was excessive, to let the 
digitalis set up a certain amount of diuresis before the full (]^uantity 
of water was ordered. Many children take it eagerly, particularly 
in the early stages of the disease. The urine was often observed to 
undergo a notable increase in the quantity of renal epithelium which 
it deposited, and the albumen usually quickly lessened in greater 
proportion than fovld be explained by the increase in the quantity 
of the urine. 

It was supposed, in one or two cases, not under my own care, 
that the treatment had a tendency to encoura^ haematuria ; and 
although I have not observed this myself, yet it must be ailmitted 
that such an occurrence is not unlikely. If the kidney be con- 
gested the escape of blood is a natural means of relief. This 
cannot take place if the tubules are obstructed through which the 
blood must come. When, therefore, the plugs are washed out 
it is conceivable that an evacuation should take place which before 
was hindered. 

The general use of iron during convalescence may be held to 
weaken the argument in favour of the other measures adopted. It 
may, however, be fairly presumed that it does not influence the 
original disorder, though it corrects the anssmia which results from 
it. As my object has been rather to benefit my patients than to make 
neat experiments, I have departed from simplicity in this respect. 

Brief notes of one or two cases may be given as examples. 

Case I. — Eliza 8., fifteen years of age, was admitted into St 
George's Hospital under the care of Dr Bence Jones, 10th Oct. 1860. 
A fortnight previously she had caught cold from dabbling about a 
street pump. The face and all the limbs swelled, and were much so 
when she came under observation. The complexion was pallid. 
She sat upright, with the shoulders supported by the arms : and it 
appeared from auscultation that two thirds of each pleural cavity 
were frill of fluid. The breathing was rapid. She coughed a good 



198 DR DICKINSON ON THE TREATMENT OF [SEPT. 

deal, and spat np broncliial mucus. She complained of pain in the 
loins, and micturition was frequent The urine was bloody and 
highly albuminous. Specific gravity 1019. The use of the 
microscope showed that it contained abundant pus cells, but no 
casts. The only treatment adopted was the admmistration of four 
pints of distilled water daily. By the 4th of November the albumen 
was reduced to a mere trace, and the colour of the urine was natural, 
excepting that it was less bright than usual. All the superficial 
dropsy had gone, and the pleural cavities gave evidence of dimin- 
ished distention. But two days later she was unwisely permitted 
to go into the garden, and blood re-appeared in the urine. Coarse 
granular casts were now discovered, which consisted of broken-down 
epithelium. The relapse, however, was temporary, and by the 
end of the month she was practically well. The albumen was so 
diminished that its existence became a question. On the 10th of 
December, she was in perfect health. The face was rosy, the pleursB 
fully resonant, the appetite great, and the urine absolutely natural. 
She now left the hospital, but returned to show herself occasionally. 
She remained in perfect nealth. 

Case II. — George T., three years of age, had an attack of scarlet 
fever which was followed within three weeks by swelling of the 
face, legs, scrotum, and belly. Diarrhoea came on, and the swelling 
subsided. The bowels remained loose after the swelling had 
entirely disappeared. He then had vomiting, which was frequent 
through the whole of one night, and in the morning three well- 
markedepileptic fits occurred in succession. He was now brought 
to the Hospital for Sick Children, and came under my care as an 
out-patient. He was visited at his own home. He was extremely 
pallid, but there was no trace of dropsv. The head was hot, the 
tongue coated, the pulse rapid — 160. The urine was scanty, it was 
the colour of dark sherry, and when boiled the clot of albumen 
occupied half the bulk of the fluid. He was ordered to live entirely 
on slops, to drink two pints of spring water in the day. and to take 
as medicine a drachm of the infosion of digitalis, with naif a minim 
of laudanum three times a-day. He had no more fits. The urine 
increased in quantity, and gave a copious deposit of epithelium and 
epithelial casts. Three days later all chance of head symptoms 
appeared to have passed away, and the tincture of sesquichlonde of 
iron was ordered in the place of the opium. Next day the albumen 
was reduced to a hardly perceptible trace, and on no subsequent 
examination could any be discovered. Within a fortnight of his 
coming to the hospital he was in perfect health. 

This example iUustrates the treatment adopted on the occurrence 
of cerebral complications. Cupping, purging, and blistering are 
believed to have disastrous effects. An ans&mic state of brain, 
of which dilatation of the pupil is a sign, is constantly founa 
after death from anssmic convulsions ; and such measures as these 
appear likely to increase the condition. Opium, on the other hand. 



1864.] ALBUMINUEIA IN CHILDREK. 199 

is its direct antagonist. It fills, instead of empMng, the cerebral 
vessels. It here seems to have been used saocessnilly as an adjunct 
to means more directly bearing upon the renal affection. Experience 
shows that convulsive attacks are peculiarly a|)t to come on after 
the exhaustion of diarrhoea or vomiting, by which the cerebral and 
other vessels are drained of their contents. 

The same measures which succeeded in this case have been used 
in others with the same result 

Case 111. — Edward L., six years of age, became an in-patient at 
the Children's Hospital, 11th September 1862. In the absence of 
Dr Hillier he fell to mv charge. A month previously he had had 
the rash of scarlatina, but the disease was slight, and in eight days 
he was going about as usual. Four days before his admission his 
face swelled slightly, and his urine was observed to be scanty. 
When seen the oedema was excessive over the whole surface, and 
the skin had a transparent waxy appearance. The albumen was 
not large in amount, but the urine was very scanty. The child was 
depressed, the tongue coated, and the case apparently one of great 
severity. He was ordered to be fed upon fluios, including plenty of 
broth, to drink three pints of water in the day, and to take a drachm 
of the infusion of digitalis eveiy four hours. Next day he was 
attacked with pain in the side, and a friction sound was heard over 
the lower part of the left pleura. No change, however, was made 
in the treatment, except that two leeches were put upon the place. 
The pleurisy passed away without the effusion of fluid, the urine 
became more copious, and the dropsy slowly diminished. On the 
17th, it was necessary to stop the digitalis in consequence of faint* 
ness. The oedema now was scarcety perceptible. A mixture of 
the acetates of iron and potass, in the proportion of two grains to 
ten, was given three times a-daj, and under its use all the remains 
of oedema disappeared, the child's aspect became ruddy, and all 
traces of albumen vanished. When he left the hospital, on the 17th 
of October, he was in perfect health, and could not nave been recog- 
nised as the same child who had been admitted a few weeks before. 

This case is brought forward in conseq^uence of the intercurrence 
of an acute inflammatory attack, and its subsidence under local 
measures, the treatment of the urinary disorder going on at the 
same time. 

In conclusion, I must express my thanks to Dr Bence Jones, Dr 
Pa^, and Dr Fuller, who have allowed me to test upon some of 
their patients in St George's Hospital the principles which I have 
here advocated;^ and I must also thank my colleagues at the 
Children's Hospital for allowing me unrestrained use of their clini- 
cal note-books. 



200 DE C. MACLAGAN ON THE ABSENIC-EATEB8 OF STYBIA. [SEPT. 



Article IL — On the Arsemo-EcUers of Styrta. By Cbaiq Mac- 
LAQAK, M.D., Edinburgh. 

{Bead before the Medico- ChinargicaL Sockty, ^ July 1864.) 

In tbe Bpring of this year, at the conclusion of a short residence in 
Vienna, I resolved to visit Italy, and finding that my route led me 
through Styria, I thought it might be interesting to endeavour, by 
personal inquiry, to gain some information as to the reputed arsenic- 
eaters of that country ; and as my travelling companion, Dr Joseph 
Butter of London, was also professionally interested in the question 
of their existence, we determined to make a short stay at Gratz, 
the capital of the duchy, and thence to make any excursions into 
the country, which the knowledge I might acquire should point 
out as necessary. 

My object in the present paper is succinctly to narrate what I 
learned by actual observation ; but before doing so I may be per- 
mitted to glance rapidly at the existing condition of our information 
on the subject. 

Althougn medico-legal observations on this practice had already 
been made so early as between 1817 and 1820 (Professor Schall- 
gruber, MedidfinJahrlmch dea Oestreich. StaateSj 1822) in Gratz, 
the first time that any great interest was manifested in Britain on 
the subject seems to have been when a paper by Dr Von Tschudi. 
which had originally been published in one of the Viennese medical 
journals {Wiener Medicinische Wochenschrijij October 11, 1851), 
appeared in an English dress, and found its way into many of the 
popular as well as scientific publications of the time, including 
Chambers's Journal, and the late Professor Johnston of Durham's 
Chemistry of Common Life. 

The embellishments which Von Tschudi's narrative received from 
other writers, as well as the apparently incredible natiire of the 
original statement, caused it to become a subject of much discussion. 
The general opinion of scientific men in this country was, that the 
statements of Von Tschudi were not worthy of beliei, and this view 
of the subject was specially maintained by Mr Kesteven of London, 
in a series of papers which appeared in the Association Medical 
Journal for 1856, in which he quotes the opinions of the most 
celebrated toxicologists of the time, in confirmation of his own dis- 
belief in the practice. 

Careful inquiry, however, was set on foot by other scientific men, 
both British and Austrian. Mr Heisch, of the Middlesex Hospital, 
having put himself in communication with persons living in the 
districts where the practice existed, was enabled to quote several 
very interesting cases, which were very thoroughly authenticated 
{Pharmaceiitical Journal^ 1859-60, p. 656), and Dr Von Vest, the 
Landesmedicinalrath for Styria, residing in Gratz, having issued a 



1864.] DB C. MACLAGAN ON THE ABSENIC-EATEBS OF 8TTKIA. 201 

circular to the medical men in bifi diBtrict, asking for information 
on the subject, was enabled also to arrive at tolerably satisfactory 
proof of the existence of the custom. The most interesting example 
of it was communicated to him by Dr Knappe, then residing at 
Oberzeiring, in Upper Styria, who had persuaded an ^^ arsenikophar 
gite" to come ana uve imder his observation for a few days, and who 
not only was thus enabled to see the man take his dose, but was 
enabled to transmit to Dr Schafer, a practical chemist in the Styriau 
capital, a specimen of the urine passed after the ingestion of the 
Srag. and which was proved to contain it. 

The facts ascertained by Knappe were made known in Britain, 
by a paper by Dr Roscoe, read to the Manchester Philosophical 
Society, and published in the Mechanics' Magazine ; and the ex- 
istence of the practice has been admitted by some scientific men 
who have written since the date of Boscoe's paper. Dr Guy 
{Foreimc Medicine^ 2d Edit, p. 368) admits that Roscoe has 
brought forward "conclusive evidence" of the fact: but from its 
being denounced as incredible in most of our standara works which 
have occasion to treat of the subject, such as those of Taylor and 
Pereira, and from its havixig been strongly denied in some important 
criminal trials, as by Dr Christison in the case of Wooler (Edifin 
burgh Monthly Journal^ 1855-56, pp. 709, 710) ; whilst Boscoe's 
valuable paper appears not to be sufficiently known, it seems to be 
the general belief in this country that there is no foundation in 
fact for the alleged arsenic-eating in S^rria. 

What seemed to result from the inquiries of Von Tschudi, Knappe^ 
and Heisch, was this : — 

I. That in various parts of Styria and the adjoining countries 
oertain individuals were in the habit of swallowing daily, or twice or 
thrice a-week, or at longer intervals, a certain quantity of a mineral 
substance, called " HiUtereich^''^ for various purposes, such as the 
improvement of the appearance, the rendering more easy the res* 
piration during mountam climbing, as a condiment, as a tonic and 
stimulant, as a prophylactic against disease, and as a preservative 
of health ; and tbat this so called Hiittereich yras arsenic 

II. That these individuals became, through custom, capable of 
taking doses of arsenic vaiying from one grain to several grains 
daily. 

IIL That its more immediate effect on the system was to make 
them lively, combative, and of strong sexual desire. This latter 
physiological effect may perhaps be held to be indirectly proved by 
the inordinate number of illegitimate children in some of these 
places, the proportion sometimes rising nearly as high as 60 per 
cent, of the total births. 

1 I use the spelling adopted by Dr Macher in his Medizinisch-statistische 
Topografie Steiermarks. Althongh the pronunciation of the Styrians makes it 
Htttrach, it is obvious that the word really is Htltten-rauch, — ^literally, Fomace 
smoke or vapour. 



202 DR 0. MACLAGAN ON THE ARSENIO-EATERS OF STYEIA. [SEPT. 

Against all this was to be placed — 

I. The experience of medical men in other countries, who have 
found that by the continued use of arsenic as a drug, even in frac- 
tional parts of a grain, certain consequences arose directly contrary 
to those experienced by the partakers of it in Styria. 

II. The want of proof by analysis that the substance said to be 
taken was really arsenic ; the absence of any chemical examination 
of the excretions of an arsenic-eater, so as to prove that arsenic 
really had been swallowed : the want of any account of its effects 
when first begun to be used ; or of any information as to the origin 
of the custom. 

Most of these objections, however^ have been removed by the 
investigations of Drs Knappe and Heisch, to the former of whom I 
am indebted for much interesting information on the subject. 

It is not at all surprising that in other countries there should be 
a prevalent impression of the non-existence of this practice in Styria, 
seeing that in Austria itself those who have not made special 
inquiries on the subject are generally sceptical as to it. Any one, 
therefore, passing through Austria and making casual inquiries, 
would most likely be told that the practice of arsenic-eating was 
not generallv known or believed in. It is not difficult to account 
for this. Tne people who e^t arsenic have the idea that it is re- 
garded as a bad habit, and therefore one to be concealed as much 
as possible, just like opium-eating in this country ; and they have 
the additional reason for concealing the practice, that from the 
strictness of the laws regarding the sale of poisons, they cannot get 
the arsenic by open purchase, as the opium-eater in this country 
can get his laudanum, and therefore they are generally obliged to 
purchase it from illicit dealers. 

I now proceed to narrate what I have myself ascertained by per- 
sonal observation. Though without an introduction to him, I 
called on the Medicinalrath, Dr Von Vest, who, on learning the 
object of mv visit, with ^at courtesy put at my command any 
papers that his office contamed, and, in addition, supplied me with 
mtroductions to Drs JKjiappe, Macher, and Tingler, the two former 
of whom I was fortimate enough to see, but I was unable to spare 
time to see Dr Tingler. 

Dr Macher, now resident at Stainz, who is thoroughly acquainted 
with all the medical matters of Styria, and whose experience during 
a long period of active professional work there, makes his opinion 
of no small value, informed me, that, although cognizant of the ex- 
istence of the practice, he had little personal experience in the 
matter. He related to me^ however, one case, in which a woman, 
who had been tried for poisoning her husband with arsenic, had 
been acquitted, from " want of evidence," the plea for the defence 
being that the man had been an arsenic-eater. Though this 
defence was generally believed to be false, it shows, at all events, 
that the practice has in a court of justice been admitted to exist. 



1864.] DR C. MACLAQAN ON THE ABSENIC-EATERS OF STTRIA, 203 

and has served; in at least one instance, as a successful ground of 
defence. 

Dr Enappe of Lie^t, in Middle Styria, an hour's journey from 
Gratz, was mj next informant ; and when I first spoke with him of 
the case of J. W., already alluded to as the subject of experiment, 
and whose urine had been examined by Dr Schafer, he described 
him as a small, strongly-built man. with a great muscular develop- 
ment, a woodcutter by trade, who nad taken the drug for a period 
of twelve years. Dr Knappe further stated to me that while per- 
sonally ignorant of the actual existence of an arsenic-eater in the 
neighbourhood, he could go with me to Upper Styria, and show 
me the above man, but he suggested that we should first make 
inquiiy in the village, whether or not any of those persons described 
to nim as indulging in the habit could not be got to take a portion 
of it before me. I accordingly slept in Liegist that night, and next 
morning I had the satisfaction, in presence of Dr Knappe and my 
companion Dr Butter, of having my first interview with an arsenic- 
eater. 

Case I. — ^Mathias Schober, a healthy-looking, firesh-complexioned, 
fairly muscular young man of the ag^ of 26 years, and about 5 feet 
9 inches in height, a native of Liegist, and employed as a house- 
servant there, said he had taken hiittereich for about a year and a 
half, not, however, white arsenic, but the yellow arsenic or orpiment, 
of which he took a specimen from his pocket and showed it me. 
Of this I retained a piece for chemical investigation. He informed 
me that he took the arsenic in order to keep strong, though he had 
never suffered from ill health. He said he never had experienced 
any bad efiects even when he first began usin^ it, that he had at 
first taken rather less than a grain every fortnignt, that he now took 
it twice a-week, and that on omitting to take it for any longer 
period, he experienced a longing for it, which was relieved by a 
repetition of tne usual dose. His reason for taking the orpiment 
instead of the white arsenic was, that it was more easily procured ; 
but having professed himself quite indifferent whether it were 
arsenious acia or the sulphuret, Dr Knappe produced a paper con- 
taining the former (of which I also kept a sample), and having 
asked him to choose out a piece such as he was in the habit of 
taking, it was weighed and found to be nearly five grains ; we had 
no finer weight than one grain, but the piece of arsenic was much 
over four, though less than five. Dr Knappe having carefully 
ground this to powder on a clean piece of paper, it was transferred 
to a small piece of plain white bread, about as large as a man's 
thumbnail, and this the doctor put into his mouth ; Schober chewed 
it and swallowed it, and then swallowed another portion of bread 
the same size immediately after. This was at 9*30 a.m. He 
stayed with us a few minutes, but he had to return to his work, 
promising, however, to come back in a short while. This he did at 
11*30, two hours after, and made water in my presence to the amount 
VOL. X.— NO. m. 2d 



204 DE C. MACLAQAN ON THE ABSENIC-EATEE8 OF STYRIA. [SEPT. 

of what I estimated at twenty-eight ounces, into a vessel previously 
carefiiUy cleaned, and the urine was put into bottles thoroughly 
washed by myself. Unfortunately, in the hurry of my departure, 
in trying to pack these bottles into my hat-box, I broke one, and 
thus lost part of the urine. Since my arrival in this country, I 
subjected the contents of the two remaining bottles to chemical 
analysis, adopting the distillation process of Dr Taylor as the most 
convenient way of separating arsenic from the organic matters of the 
urine. For this purpose the urine was carefully evaporated to dry- 
ness in a clean retort; the nearly dry residue was covered with 
strong hydrochloric acid, and distilled into a well-cooled receiver. 
The product, amounting to about half an ounce, was a clear, feeblv 
pinkish fluid, thirty minmis of which, when treated both by Beinsch a 
and Marsh's process, gave very characteristic arsenical deposits. 

Schober also came the following dav to see me, having taken no 
more arsenic since the dose which he had swallowed before me 
twenty-six hours previously. I again secured some urine which he 
passed in my presence, and this, when chemically examined as 
above, also yielded arsenic freely. 

Case II. — Joseph Flecker, at. 46, a muscular, healthy-looking, 
dear-complexioned man, a tailor by occupation, told us tnat he hs^ 
taken hiittereich, generally the orpiment, for a period of fifteen 
years. He first began to do so, on tne occasion of tne inhabitants of 
a house, in the neighbourhood where he lived, being attacked with 
fever; and when fourteen people had died in it, ana no one would 
enter the premises, he determined to do so, and took, as a pro* 
phylactic, about one grain of arsenic daily for three successive days, 
while going to the infected house, and though he said he had not 
felt quite well at the time, he was unable now to describe specially 
what had ailed him ; but on being asked if he had ever suffeim from 
vomiting or irritation in the stomach, he said he never had. 

The day before my interview with him, he twice, viz., at 10*30 
and 3 o'clock, had, in the presence of several of the villagers of 
Liegist, and on one of those occasions in presence of the bur^r- 
meister, who informed me that he had seen nim do it, taken a piece 
of the sulphuret of arsenic from his pocket, and scraped ofi* a certain 
quantity of it on a piece of bread and eaten it. He brought with 
him a small bottle of^his urine, which he stated to have been passed 
eighteen hours after the last oi the two doses, and in which 1 have 
since found a considerable quantity of arsenic. The reason which 
he assigned for this public exhibition of his arsenic-eating capacities 
was, that it had become the subject of conversation in tne village, 
that two strangers had come a very considerable distance to witness 
an example of arsenic-eating, and inquire into the practice, and that 
he wished to make open demonstration of his assertion that he waa 
capable of tolerating a considerable dose of arsenic. When he first 
came to me, he seemed somewhat unwilling to take a dose that day, 
owing to his previous performance, and seemed to fancy it possible 



1864.] DR C. MACLAQAN ON THE ABSEKIO-EATERfl OF STYRIA. 205 

that he might have some slight irritation of the stomach, such as a ^ 
feeling of warmth accompanied bj thirst He did not appear to BST* 
able to give any reason tor anticipating this result ; perhaps he il^4- 
tended it as a sentle hint that the thirst might require assuaging ; 
at all events, having been informed that he shoiud not want the 
wherewithal to quench it — (he confessed to being by no means 
abstemious in the matter of alcoholic potations), he, to satisfy our 
curiosity, picked out a piece of arsenious acid, from the same parcel 
that had been shown to Schober, and which, on being weighed, 
was found to be as nearly as possible six ^ains. This he placed 
entire on a small piece of bread, and tuing it into his mouth, 
crunched it up audibly, and in about two minutes after swallowed 
six or seven oimces of cold water, stating that he liked to drink 
immediately after swallowing a dose, ana on such occasions pre- 
ferred water. I then made him open his mouth and inspected it 
narrowly, but found it quite clear of bread crumbs or anything else, 
thus assuring myself that no jugglery could have been practised. 
Aftier having swallowed the arsenic four minutes, he enictated 
slightly, but till he left us, a Quarter of an hour after, he had no 
symptoms of any bad effect. The six grains were taken at 11*30, 
and at 12'15 he returned, and passed a small quantity of light- 
coloured urine. Nearly the whole of this was bottled for exporta- 
tion, and the twelve ounces thus secured were treated by the 
process of distillation above described, and also yielded a charac- 
teristic deposit of arsenic 

Flecker gave me the following account of his use of arsenic. He 
stated that he generally takes about the quantity we saw him 
swallow once a-week, but with variations in the intervals, there 
being sometimes four days only, sometimes eight days between the, 
doses. That when he has a distance to walk to his work, he takes 
a larger dose, and is then in good spirits for about eight da;^s. 
That if he, however, intermits it for fourteen davs, he feels stiff 
in the feet, with general lassitude and a craving ror another dose. 
If his victuals are hard of digestion, he takes a dose to assist the 
stomach, and if he takes a rather ftiU dose, he brings a good 
deal of wind off his stomach, but never vomits. He stated that his 
father had taken arsenic beiore him, and in considerable quantity, 
and that .in the immediate neighbourhood of Liegist numbers use it. 
several taking it daily, and many in larger doses than he. He said 
that all who take it are healthy, — that he never knew of any one 
vomiting from its use, and he believed that, like the use of tobacco, 
if the dose is veiy gradually diminished, an arsenic-eater can break 
himself of the habit. * 

One of the objections which has been made to the acknowledg- 
ment of the reality of arsenic-eating is, that the substance swallowed 
has not been ascertained by chemical examination really to be 
arsenic. This link in the chain of evidence, I am able to supply. 
The white substance which I saw Schober and Flecker swallow, 



206 DR C. MACLAQAN ON THE ARSENIC-EATERS OF STYRIA. [SEPT. 

fart of which I have now in my possession, is pure arsenious acid, 
t sublimes into octohedral crystals, and leaves no appreciable 
residue. The yellow substance which Schober used is a fair sample 
of the orpiment of commerce, and contains, as that substance usually 
does, a considerable proportion of free arsenious acid. 

I am, of course, not m a position to give any opinion as to the 
extent to which arsenic-eating prevails in Styria, — my time would 
not have permitted me to enter upon such an inquiry, nor would it 
be easy to get satisfactory information as to a practice which is 
generally kept secret ; confirmation of the fact of its existence is 
more interestmg to us scientifically than its extent ; and that it is a 
fact, my personal observation enables me confidently to affirm. 
That arsenic-eating is in Styria a universal habit, or one indulged 
in by even a majority of the male peasantry, I do not for a moment 
suppose ; but the averment " that the story of the Styrian arsenic- 
eaters is not only unsupported by adequate testimony, but is 
inconsistent, improbable, and utterly incredible " (Kesteven, Asn. 
Med. Journal^ 1856, p. 811) ; or that these are " absurd and ex- 
aggerated statements, utterly inconsistent with all that is known 
concerning the action of arsenic in this or other countries, and but 
for the fact that they for a time received the literary support of 
Professor Johnston, and were diflused by him in an amusing book, 
they would not have required any serious reftitation " (Taylor, On 
Poisons, 2d Ed., p. 92) ; or that it is a " mess of absurdity," " a 
pure fable," (Christison, JEdtn. Med. Journal^ 1855-56, pp. 709, 710), 
are, although justified by the state of knowledge at the time they 
were made, no longer tenable ; but, on the contrary, we can no 
longer doubt, to use nearly the words of Boscoe, " that decisive 
evidence has been brought forward not only to prove that arsenic is 
well known and widely distributed in Styria, but that it is likewise 
regularly eaten in quantities usually considered sufficient to cause 
immediate death." 

It is probable that many of the physiological actions attributed to 
it are fanciful, and that its use is mixed up with a good deal of 
superstition, as, for example, in the case of tne poacher who takes 
it to give him courage to pursue his depredations on ground that is 
new to him, or that of the ostler who, m giving it to his horses to 
improve their coats, thinks that it will have no beneficial efiect 
unless he partakes of it at the same time. 

It is evident that the confirmation of the existence of the practice 
of arsenic-eating must lead us to modify some of the opinions that 
are entertained with regard to the influence of habit on the action 
of poisons. It has long been notorious, that by habit the human 
boay may be brought to bear with impunity doses of organic poisons, 
such as opium, which, to those unaccustomed to them, would 
certainly prove fatal; but "it has hitherto been considered by 
toxicologists that, except within very narrow limits, habit appears 
to exercise no influence on the action of mineral poisons" (Taylor^ 



1864.] DR G. MACLAGAN ON THE ABS£NIC*EAT£B8 OF 8TYKIA. 207 

On Poisons^ p. 89). Though the experiments of M. Flandin. by 
which he proved that he could brin^ dogs to bear doses of fifteen 
grains of arsenious acid in powder m twentj-four hours without 
injury to their appetite or health; and the practice of administering 
arsenic to horses, nave long been known as pointing rather in the 
contrary direction, this has been supposed to be due to some 
peculiarity in the constitution of the lower animals. The facts 
which have been ascertained with regard to the Styrian arsenic- 
eaters, and which the above observations confirm, entitle us to 
maintain that the modifying effect of habit is not confined to organic 
poisons, but extends to those of mineral nature, at all events to 
arsenic. 

28 Heriot Row, Edimbubgh, T^th June 1864. 



Article III. — On the Wire Compress as a Substitute jor the 
Ligature. By John Dix, M.K.C.S., L.S.A., Surgeon to the 
Hull and Sculcoates Dispensary, etc., late Assistant-Surgeon 
British Civil Hospital, Benkioi. 

About five years ago, Dr Simpson of Edinburgh proposed to the 
surgical world the use of needles instead of ligatures, as a means of 
arresting the bleeding firom wounded arteries; which method he 
called "acupressure.'^ Coming from such a source, it naturally 
attracted some attention, and was soon pretty extensively tested by 
various surgeons — mostly provincials. It was found to be prac- 
ticable, effectual, and safe, and bv some it was supposed to possess 
considerable advantages. By others, chiefly, I believe, those who 
had not tried it, it was sneered at ana almost abused. 

It cannot be said to have made much way in the world. A few 
surgeons still continue to employ it — some have given it up. A large 
majority have never tested it at all, especially in London, where, 
so lar as I know, scarcely any operator of note has adopted it. 

It does not clearly appear in what respect acupressure has disap- 
pointed those who have used it — there are as jtt no published 
opinions on the point, — ^but it is a noticeable, and rather encourag- 
ing circumstance, that at a debate at the Medico-Chirurgical Society 
of Edinburgh, where the subject was lately introduced by Dr 
Handyside, the opposition consisted altogether and entirely of non- 
experts, whilst all who had tried it spoke in its praise. 

For myself, I early made trial of the needles. My case — an 
amputation of the arm — is published in detail in the Medical Times 
and Gazette of 2d June 1860. As there related, I was to a certain 
extent pleased with the process ; but I also observed in it certain 
inherent disadvantages. 



208 MB DIX ON THE WIRE G0MPRE8S [SEFT. 

Most, or all of these, as it seemed to me, might be obviated by 
the use of a fine iron or silver wire instead of the steel needles, the 
principle of action being the same, and the mode of application not 
dissimilar. 

So soon as opportunity offered, I put this idea to the proof. The 
results are the subject-matter of this paper. 

Having satisfied myself of its feasibility by some experiments on 
the dead, I first used the wire on a living subject in a case of 
amputation of a finger, in September 1860. 

The patient was a woman, aged 50 years, affected with consti- 
tutional syphilis, the second finger of whose right hand required 
removal on account of caries. The head of the metacarpal bone 
was covered over by a single flap, taken from the internal lateral 
aspect of the finger. Two arteries were secured by compression — a 
fine silver wire being used for that purpose. These wires were 
removed on the third day. There was no bleeding, and the wound 
healed readily, though not absolutely without suppuration. 

Encouraged by this success, and convinced of its safety, I next 
used the " wire compress " — ^as I proDose to designate this method 
— ^in the same patient, upon whom Cfhopart's amputation was per- 
formed (April 26, 1861), for extensive disease of the cuneiform and 
adjoining metatarsal bones. 

The operation was done in the usual way — a long flap beinff cut 
firom the sole of the foot. Five bleeding arteries were secured by 
silver wire, in the way about to be described. The flap was care- 
fully adjusted, with many sutures of iron wire, and from the ap- 
pearance of tne stump, the universal verdict of bystanders was, 
" that seems a great improvement on the needles." 

On the 28th, viz., forty-eight hours after, four of the wires were 
withdrawn without diflSculty and without bleeding; and on the 
30th, or fourth day, the remaining wire, which commanded the 
posterior tibial artery, was in like manner removed. It was found 
that the wire was easily applied, as easily taken away, and entirely 
effectual for the purpose it was intended to serve, viz., the arrest 
of the bleeding firom the cut vessels. 

The patient, as I have before explained, was the subject of con- 
stitutional disease, and the case did badly fi*om the first. There 
was sloughing-of the entire surface of the wound, and this process 
gradually involved the substance of the flap, which was ultimately 
almost entirely destroyed. 

This was an unfortunate thin^ for the patient, and not very 
satisfactory to the surgeon ; but it was certainly advantageous to 
science, inasmuch as it put this method of secunng arteries to the 
severest possible test, and also gave me an opportunity of observing 
the process and its effects more closely and accurately than would 
otherwise have been possible. 

So soon as the sloughing action set in, the sutures were removed, 
and the flap opened out, and thoroughly cleaned by gentle washing. 



18e4.] AS A SUBSTITUTE FOR THE LIGATURE. 209 

Thus it happens that I am in a position to speak positively about 
the action of the wire compress upon the arteries so treated. It 
was found then that the continuity of the vessel was not destroyed 
where it was compressed by the wire ; it was not divided, nor was 
its terminal portion cut through as by the ligature. The patulous 
end was securely sealed and closed, instead of sloughing away, as 
necessarily happened when a silken thread was &stened there- 
upon, which could only be got rid of by destruction of the tissue 
upon which it was fixed. 

Nor can anything more clearly prove the firmness and security 
of the adhesion, which this process excites in the vessel itself. 
Eveiy surgeon knows how common is secondary hsemorrhage in a 
sloughing stump, and understands the reason why. I certainly 
expected it in this case. I think I have observed before, in cases 
of hospital and other forms of gangrene, that an artery is by no 
means the first tissue to slough, its tough and well-nourished 
coats often resist the destructive process longer than surrounding 
textures, and the length of time required for a ligature to become 
detached firom a lar^ artery, confirms this view. 

But however this may be, it is certain that in this case the 
divided ends of the arteries exhibited healthy granulation, whilst 
other tissues were sloughing around. I shall have occasion to 
refer to this highly important and interesting observation again by 
and by. 

This patient progressed from bad to worse; unhealthy suppura- 
tion ana sloughing extended up the ankle in the sheaths 6f the 
tendons, and erelong pyaemia set in — of which she died on 9th 
May, being thirteen days after the amputation. 

1 related these cases at a meeting of the East York and North 
Lincoln Branch of the British Medical Association, on 22d May 
1861. 

The third and last case in which I have used this method was 
an amputation of the thigh, of which the following is a brief 
histoiy : — 

A. W., aged 20 years, had suffered from disease of the right 
knee-joint for 11 years, by which he was so dwarfed and emaciated 
that his appearance was that of a child of 14. There were sixteen 
discharging sinuses, and his weight was three and a-half stones. 

2l8t Sqptemher 1861. — ^Amputation was performed according to 
Mr Luke's plan, viz., the posterior flap was first made bv trans- 
fixion, and the anterior, of exactly similar size, by cutting from the 
surface down to the bone. The bone was sawn at the junction of 
the middle and lower thirds. Five wires were applied upon as 
many arteries, and with the femoral artery the femoral vem was 
intentionally included. Two small arterial branches were treated 
by torsion. The flaps, which fitted well, were accurately adapted 
by means of wire sutures, pads of lint, and strips of plaster. 

The case went on favourably in every respect ; there was very 



210 MR DTX ON THE WIRE COMPRESS [SEPT. 

little bleeding at the operation, and none afterwards. The lad 
immediately ate and slept well, and was evidently much relieved 
by the removal of the offending member. 

On the 24th, being seventy-two hours after the operation, four of 
the presse-artfere wires were withdrawn with perfect ease and with- 
out bleeding. The wire upon the femoral artery remained till the 
26th, that is, five days altogether, when it too was removed, without 
any difficulty and without a trace of blood. At this time consider- 
able union had taken place between the flaps, but there was slight 
suppuration about the deeper parts ; so that when I related this case 
at a medical meeting on October 9th, being the eighteenth day 
after operation, I spoEe of it as a forward stump, and hoped for an 
early cure. In this I was disappointed ; for although the lad im- 
proved in health and appearance, and was soon walking stoutly on 
crutches, still the stump did not heal. Three or four sinuses 
remained, discharging pus of a thin unhealthy character; the 
granulations were feeble and flabby, with occasional outbursts of 
more acute suppuration. 

The explanation of all this was subsequently found in a necrosis 
of the sawn end of the thigh bone. A considerable ring of this 
was gradually loosened, and cast off in the usual way ; and when 
found to be detached was removed by an incision made into the 
face of the stump. In a few days after this the whole was soundly 
healed. It has continued so ever since ; the lad walks particularly 
well on a common wooden peg leg, and is now ripening mto a man, 
and earning his own livelihood as a railway clerk. 

What then do these cases prove with regard to the method 
employed for securing the vessels ? Simply this, that it is prac- 
ticable, efficient, safe, and manageable, nothing more. As yet I 
can show no positive results better than iiiight have been obtained 
by the use of ligatures in the usual way. The great desideratum, 
primary union, has not as yet been arrived at. Any advantages 
then that may be claimed for this procedure at present rest chief y 
on theoretical grounds ; not aUogether so either. Surely it has some 
superiority, indisputable and d^emonstrable, over the ligature, as I 
now propose to show. In pursuance of which object it will be 
convenient, first, to consider the effect, action^ and results of the 
ligature. 

It will probably be conceded by most surgeons, that a ligature is 
at best a necessary evil. It is a great nuisance in a wound, and 
the chief obstacle to primary union in many operations, and espe- 
cially in amputations. Union by adhesion, after a large amputa- 
tion, is an occurrence of extreme rarity. The recollections of a long 
surgical experience fiimish but here and there an isolated case. 
Many men will say they have seen it once (I have met with no one 
;who has seen it more than once), whilst many do not believe in it 
at all, and even doubt its possibility. 

But how constantly does one read, in reports of surgery, such a 



1864.] AS A SUBSTITUTE FOB THE LIOATURE. 211 

sentence as this : ^' fifth daj, complete onion eascept in the track of 
the ligatures^ Such cases eveiy one has seen ; thej are common 
enough. Surely then the inference is not far-fetched or illogical, 
that, but for the ligatures^ suppuration might often be altogether 
avoided. What; indeed^ is a thread of silk or hemp between the 
flaps but a miniature seton I The whole number or ligatures col* 
lectivelj would form one of considerable size, and are a necessarj 
and certain exciter of suppuration : such a seton being, in fact, the 
yeiy means we use when we wisn to set up or to maintain this 
process. 

Again, how is a ligature detached from the vessel to which it has 
been applied? Why, bj ulceration I another unhealthy and objec- 
tionable process. The part of the artery encircled by the thread 
dies by strangulation, whilst a further portion, which has been 
drawn out and detached from its sheath for the application of the 
ligature actually sloughs away. 

This drawing out of the artery hy the forceps is of itself bad, as 
it breaks up the vascular and nutritive connexions of the vessel, and 
BO retards those vital and physiological processes bv which the 
closure and permanent sealing up of the cut tube is effected. How 
frequently, too, is this disturbance of the vessel itself, and of the 
reparative action going on around and within it, renewed by traction 
made on a ligature, supposed to be detached when it is not really 
so. In this way also it occasionally happens that a considerable 
piece of the artery above the site of the ligature is plucked away, — 
fully half an inch I have seen ere now. 

The suffering occasioned by this experimental traction, be it 
futile or successftd, is horribly familiar to every patient, and dreaded 
by every humane dresser. The pain of dressing a stump is over 
when once the ligatures are all out. 

The knot of a ligature (often deeply buried between the flaps) 
cannot be withdrawn without breaking up whatever adhesion has 
taken place between the site of the artery and the edges of the 
integument Hence, will occur bleeding from torn granulations, 
and manifest derangement of the healing process. 

Again, a ligature once applied, the surgeon is at its mercy (so to 
speak), and the patient too. Who can say when it will be thrown 
off? I know a gentleman who carried one in his arm eleven 
months afler amputation. I remember another, who, having had 
his testicle excised, had two ligatures remaining in the imhealed 
wound to the day of his death, which happened several weeks after 
the operation. It is obvious that so long as a thread remains a 
complete cicatrization is impossible. 

But I must push this argument a little further. I need scarcely 
dilate on the advantages of primary union could it be obtained. 
Time is an important element in most cases. A cure by adhesion 
is the work of but five or six days, the secondary processes require 
nearly as many weeks ; but there are other considerations far more 

VOL. X.— NO. ni. 2 E 



212 MR DIX ON THE WIRE COMPRESS [SEPT* 

important than this. For instance, what are the chief sources of 
danger from amputation ? 

First and foremost, the much dreaded pyaemia ; which, it is said, 
kills half those who die after amputation. 

And the parent of pyaemia is suppuration. So soon as the secre- 
tion of pus commences so soon is tnere danger of purulent infection, 
which occurs not at all during healthy adhesive repair. Who "will 

Sinsay the intimate relation between suppuration and the ligatures? 
ave we not seen that they are almost inseparably connected, and 
that the ligature may be, and indeed often is, an active source of 
pus formation. 

The next most fatal accident is secondary haemorrha^, which 
arises chiefly or altogether from the ulceration or sloughing of an 
unsealed artery. And have we not proof that this very ulcerative 
process is set up in the vessels themselves by the ligatures? It is a 
necessity of the case, part and parcel of the natural action of the 
thread, which cannot in any other way be got rid of. On the other 
hand, it is not very clear why, except for this necessity of casting 
oflf the foreign body, ulceration of an artery should ever occur, at 
least in a healthy stump. Yet it happens not imfrequently that 
bleeding occurs, even when reparation is well advanced, and every- 
thing appears to be going on ravourablv. 

Surely these are striking and remar&able facts, and demand our 
most serious attention. Here are two unhealthy processes, the 
grand sources of the most fatal sequelae of amputation, shown to be 
intimately mixed up with or actually inaugurated by the very 
means we use to stop the bleeding. I said that a ligature is at best 
a nuisance. I hope to show that it is no lon^r a necessity. 

Yet I am prepared to hear, as I have heard before in discussions 
on this subject, that some surgeons are content with the results of 
the ligature. 

Such I would ask to call to remembrance their cases of pyaemia 
and secondary haemorrhage following operations, and to remember 
that in their ligatures they have, to say the least of it, a possible in- 
cerUive to both these dangers. 

I entreat them to ponder over the following formula : — 

Pyaemia is the offspring of purulent formation, of which the 
ligatures are an efficient and probable cause. 

Bleeding arises solely from ulceration of a bloodvessel, of which 
the primum mobile is again the ligature. 

Cfontrast with the fcregoing statement (unexaggerated and un- 

frejudiced, as I believe), the effects and action of the wire compress, 
unhesitatingly assert that, from one and all of these objections to 
the ligature, it is almost or altogether free. 

Thus, it has not to be detached by ulceration, neither does it 
give rise to this unhealthy and undesirable action. On this point I 
speak positively from absolute proof, as related in Case II. 

It has little or no tendency to excite suppuration, and certainly 



1864.] AS A SUBSTITUTE FOR THE LIGATURE. 213 

does not necessarilyi or even usually^ occasion it. This is in 
accordance with the well-known jpatnological law, that metallic 
snhetanceSy from not absorbing fluids, and perhaps from other 
causes not so well understood, are freely tolerated in the living 
body, and often remain therein embedded with perfect impunity for 
an^ length of time, not causing suppuration, ulceration, nor even 
imtation. Frequent experience of metallic sutures has proved this 
to the satisfaction of most surgeons, and it needs not to be further 
dwelt on here. It is an accepted fact in surgical pathology. 

Again, the wire compress is applied without oisturbance of the 
natural relations and vital connexions of the vessel. It is removed 
at any time according to the will and judgment of the surgeon, 
without any interference with the adhesive repair which may have 
taken place in the artery, and in the rest of the stump, almost without 
pain to the patient, and entirel^p- without those torturing attempts and 
uncertain trials wnich appertain to the withdrawal of the ligatures. 
To which, I may add, tnat the wire once properly applied, is not 
liable to loose its hold, or become detached too soon, as not unfre- 
quently happens when a thread is tied upon a brittle diseased 
artery, or upon a bleeding vessel in a slouching wound, as, for 
example, in secondary haemorrhage from hospital grangrene, — that 
twigs of nerve, if accidentally included in the embrace of the wire, 
are not injured and excited as by the tight strangulation of a 
ligature. Hence there will be but little or no twitching and 
jumping of the stump, which was an observed fact in the cases here 
narrated. 

And, lastly, it is quite easy to compress the adjacent veins along 
with the arteries if it be deemed desirable. It is certainly well to 
do this if the veins show a tendency to bleed, as thereby all oozing 
and formation of coagula between the flaps — than which there is 
no greater obstacle to primary union — is entirely prevented. Even 
those who fear to tie a vein need not dread any ill results from the 
simple compression of it. 

Surely all these collectively form an aggregate of no mean or 
trivial advantage as compared with the ligature. 

It may be thought that the few cases in which this plan has been 
tried, are but a small experience on which to speak so confidently, 
and almost didactically. It is right, therefore, to state, that what is 
here advanc^ is deduced not from these cases alone, but also from 
the recorded results of acupressure, which has been successfully 
used in numerous instances, and which offers man^ of the advan- 
tages, and confirms most of the conclusions on which is based this 
advocacy of the " wire compress." This is in reality but a modifi- 
cation of acupressure, from which it differs in detail rather than in 
principle or modus operandi. Hence it is that I lay no stress on 
originality in the matter ; this merit, so far as I know, belongs to 
Dr Simpson alone. Yet, I believe the substitution of the wire 
for the needles to be a decided and important improvement, 



214 HB DIX ON THE WIRE COMPRESS [SEFT. 

as i< is free from most of, or I may say all, the shortcomings of 
^^ Simpson^s skewers," as the acupressure needles have been irre'* 
verently called. 

The following may be mentioned as the chief defects of the 
needles : — ^When several of them are required, the stump resents as 
it were being thus pierced through and through in many places 
and in various directions. From this cause, and from the obstruct 
tion to the capillary circulation caused by the pressure of the un- 
yielding steel, we nnd much tension, oedematous swelling, and in 
some cases very great pain. The pain especially has proved a very 
serious evil, so much so as to lead one surgeon to my knowledge 
to abandon the use of the needles entirely. Again, their projecting 
ends, and the puckering they cause in the substance of the flaps, 
interferes very much with that accurate adjustment of the cut sur- 
faces and edges, which so greatly aids the chances of union bv 
adhesion. None of these objections apply to the " wire compress. 

The first point is with regard to the mode of application of the 
wire, which may be best .done in the following manner : take a 
piece of surgical wire, 6 or 8 inches long, and thread each of its 
ends upon a straight needle. 

Seize the bleeaing mouth of the arteiy with forceps, and pass one 
of the aforesaid needles close on each side of the artery, about a line 
above the points of the forceps, directly down through the substance 
of the flap, so that they emerge at the cuticular sunace, about half 
an inch aistant from each other. Draw them both through together, 
till the curve of the wire compresses the vessel on the face of the 
flap. Now, get rid of the needles by clipping through the wire close 
above their eves, also detach the artery forceps. Place a piece of 
cork cut for the occasion upon the skin between the points of exit 
of the wire, and over this twist the wire tighter and tighter till the 
bleeding is arrested. Lastly, cut off the superfluous wire. All 
which is done much quicker than described. Eepeat this process 
upon as many vessels as require it. 

Two arteries Ij^ing near together majr be embraced by one wire ; 
and, as I have said, the veins may be included or excluded at will. 

The wire should be either silver, or, what is much cheaper and 
equally manageable, the finest and softest passive iron. The 
generality of tne iron wire used for sutures is too hard and stiff. 
That which I have employed was supplied by Mr W. B. Hilliard, 
surreal-instrument maker^ Glasgow, who also furnished the needles, 
which are about 3 inches m length, straight, and three-edged, with 
an eye adapted for carrying wire. 

Special care is necessarv in threading the wire, that it be kept 
perfectly firee from all kinking or twisting. The forceps are used, 
not to draw out the artery, as when a ligature has to be applied — 
this, indeed, is to be particularly avoided — ^but merely as a guide to 
mark the exact position and course of the vessel. The cork is 
necessary to protect the skin from the pressure of the wire. The 



UB64.] AS A SUBSTITUTB FOB THE LIGATUBE. 215 

stnmp will now be dressed accordiBg to the fashion of the opera* 
tion. 

Of course, objections will be raised to this scheme. The onlj one 
to which I need reply by anticipation, is that which natiurallj 
occurs to any one looking at the tninff for the first time. How it 
that wire to be toiihdratm t This, at first sight, appears an insuper- 
able difficulty. Let any one who entertains that idea try the 
experiment on the dead subject, and he will probably be surprised, 
asl was, to find how easily and certainly it is efiectod. To which 
he may add, my eapertmentum cruets^ that it is equally eas^ and 
certain in the living body. Here, I ought to mention, that it was 
fi*om Mr Hilliard I first learnt that the abrupt bending of the wire 
is not an impediment to its removal. He also suggested to me the 
use of two needles in the way just described, by which the wire is 
applied much more expeditiously and exactly than by using a single 
eedle. The only conceivable obstacle to its withdrawal would ne 
a kink or hitch in the wire^ which might cause much inconvenience. 
Hence the stress I have laid on the necessity of carefully avoiding 
this mischance in threading and fixing the wire. Its removal, no 
doubt, requires to be cautiously conaucted. Thus, clip the wire 
close to the ed^ of the piece of cork, and straighten out the curve 
it has necessanly formed at its exit from the skin. Remove the 
cork, and apply instead the tip of one finger, with which press 
firmly upon the flap, making traction, gently and gradually, upon 
the other end of the wire. In this way it comes out with great 
facility ; but if this were roughly and harshly done, it might break 
up the adhesion which we suppose has taken place between the 
surfaces of the flaps, and it is quite possible that a kink in the wire 
might lacerate the artery in passing over it. 

^Dut it is certain that none of these evils need happen with ordi- 
nary care and tact. 

As to the period of withdrawal, farther observations are desir* 
able ; but it has been shown, in numerous cases of acupressure, that 
for small vessels a few hours of compression is sufficient ; and for 
the largest arteries a much less time than might, a priori^ have 
been supposed. However, as a general rule, it is not desirable to 
disturb a wound in any way for from twenty-four to forty-eight 
hours, at the end of which time all wires commanding the secondary 
branches may be safely removed, and probably also from the large 
arteries ; but, as a matter of prudence, one would at present prefer 
to keep a check upon such an one as the femoral for three or four 
days at least Better it should remain needlessly long than be 
prematurely removed, for, as has been said repeatedly before, the 
presence of the wire is almost innocuous. 

Hitherto I have spoken of this method of securing arteries only 
in reference to amputation of limbs. It is equally applicable to 
many other operations. Thus, supposing the testicle to be excised, 
how easily and nicely the vessels of the cord may be compressed by 



216 MB DIX ON THE WIBE COMPRESS [SEPT. 

a wire; safely removable in. a few hours. In a case of this kind, 
operated on a year ago, two ligatures were applied. One of these 
did not come away for nineteen days, during which time, of course, 
many attempts had been made to withdraw it, amid the grimaces 
and exclamations of the patient. Moreover^ most of the wound 
healed by first intention, and I am firmly oi opinion that but for 
the li^ture there would naye been no suppuration. 

This method would also be particularly suitable in a case of 
popliteal aneurism. I would ask special attention to this, for in no 
case are its advantages more obvious and decided. Surely such a 
wound as that made during the operation, a single clean incision 
on healthy tissue, might reasonably be expected to heal at once, 
were it not for the foreign body, the ligature or seton, which keeps 
it open. Moreover, the ligature remains some eight or ten days, 
long after it has ceased to be necessary or useful ; and above all 
things in the way of objection, it seta up vJceraMon^ by which it has 
to cut its way through the vessel before it can be detached, whereby 
the blood channel is opened, and hemorrhage may and sometimes 
does result 

Suppose such a case treated by the wire compress. The wire 
would be passed under the artery by means of a tubular aneurism- 
needle made for the purpose, then brought through the integument 
at a convenient situation, by threading each end upon a common 
needle, and twisted upon a cork in the usual way. And now, 
mark the contrast. I have shown that in amputation of the thigh, 
the severed femoral is securely closed in three or four days by the 
action of metallic pressure, and there seems to be no reason why 
the same thing should not happen here ; from which it follows that 
the wire might be safely removed in four days. Whilst there, it 
would be innocuous, not exciting suppuration ; and in the end 
the coats of the artery would remain intact, and bleeding would be 
impossible. 

Surely these are great and manifest advantages ; as yet theoretical, 
I grant, but nevertheless self-evident, and based on sound reason- 
ing and very exact analogy. 

It will probably be found that the pedicle in ovariotomy may be 
conveniently dealt with by this method, the arteries being secured 
individually, and the entire stump also fixed to the abdominal wall 
by another wire. This idea has been already promulgated by my 
firiend Mr Spencer Wells. 

To some wounds the wire compress is inapplicable. Thus, in 
the removal of a breast, it is usual to have bleeaing firom the twigs 
of the intercostal vessels which pass upwards through the muscles. 
Upon these the wire could not be applied ; and the same difficulty 
might arise in the removal of any deep-seated tumour. 

In these cases the short needles of JDr Simpson have been found 
to act well ; but I have elsewhere ^ven reasons why the wire is 
preferable where it can be used. Neither should I expect to find it 



1864.] AB A SUBgTITUTE FOR THE LIGATUBE. 217 

easy to apply the wire upon the vessels of a flat-faced stomp made 
by the ciicmar incision. But this is merely an additional reason, 
if such were needed, for preferring a flap operation. 

It is scarcely necessaiy to allude to the idea, recently put forth 
as a novelty, of using vnre as a Itffature, by tying it upon the 
arteries. It is neither new nor good, for it is evident that ity like 
any other ligature, can only be cast off by ulceration, which pro- 
cess, as we have seen, the metallic substance does not readily excite, 
and therefore it would probably be more difficult to cet rid of than 
even the old-fashioned thread. Nor, I suppose, wiU any stress be 
laid upon the now exploded doctrine, that lor the safe closure of an 
artery it is necessaiy that its inner coats should be divided. The 
results of acupressure have sufficiently shown the non-necessity of 
this. It is certain that the needle passing over an artery can 
effect nothing of this kind, and yet, by its use, secure and firm 
obliteration does take place, and that readily and speedily ; from 
which it is evident, that if such a necessity existed about the 
beginning of this century, when the doctrine was first invented by 
Jones, it is no longer needful at present. Nowadays it is sufficient 
that the current of blood shoula be arrested for a few hours by 
siinple pressure.* 

I take it for granted, that some who read this paper will, ere- 
long, be making trial of this contrivance. I woula warn such 
against disappointment which might arise, from anticipating too 
much, and also at the same time protect myself from suspicion of 
exaggeration and extravagance. Therefore, let it be borne m mind, 
that entire union by adheswn in large wounos is not to be expected 
as a firequent event, neither will pysemia and secondaiy haemorrhage 
be utterly abolished. But it cannot be denied, that ligatures are 
an impediment to healing, and that the absence of these impedi- 
ments increases the probabilities of union ; that the presence of a 
ligature in a suj^purating wound increases the suppuration and pro- 
longs its duration ; and that the longer the period of purulent 
formation, the longer the danger of pysemia exists, and the greater 
are the chances of the occurrence of this bane of surgery. 

And if my statements should appear in some degree sanguine and 
enthusiastic, this arises solely from the implicit confidence I feel in 

^ It is more than likely that this laceration of the internal coats of an 
artery, so far from being essential to its repair, is in reality detrimental. 

An artery is a living stractare, endowed with the same vital properties as 
other tissues, and is healed by similar processes. It is clear that the ligature 
inflicts an additional injury on the wounded vessel, by tearing and bruismg it, 
converting " a simple incised wound ^^ into " a contused and lacerated wound." 
This we are told acts beneficially by exciting " adhesive inflammation.'^ Is not 
this altogether a fallacy? Improved pathology teaches that there is not 
merely a distinction, but an actual antagonism between inflammation and 
adhesion, and that the grand essential of repair is "physiological rest.*^ 
'What makes an artery a solitary exception to this law of nature? Why 
should it alone of all structures be subjected to those very curious and 
•eccentric aids to healing — contusion and laceration ? 



218 



ME DIX ON THE WIRE COMPRESS 



[SEFT, 



the intrinsic merits of the little device just propounded. I have 
met with no difficulties or drawbacks that have not been frankly 
narrated, nor am I acquainted with any dangers that can be alleged 
against it ; and, for myself, I should as soon think of stuffing a 
wound with charpie, or of searing a stump with a red-hot iron, as 
of using a ligature where the wire could be applied. 

Allow me, then, in conclusion, to give in few words, a tabular 
resum^ of the points of contrast between the ligature and the wire 
compress. 

The main distinctions are these : — 



The ligature consists of organic 
material. It absorbs fluids of 
the wound — is itself liable to 
decomposition, and is very ob- 
noxious to the living structures. 

The ligature is nxed to, and 
fastened upon, the artery itself. 
It lacerates its structure, and 
puckers up and corrugates the 
tube. 



The wire being a metallic sub- 
stance is non-absorbent — non- 
irritant, and almost innocuous to 
the tissues. 

The wire is not attached to 
the vessel, nor indeed to any- 
thing else ; it does not tear the 
coats of the artery, but closes it 
in a smooth and even manner, 
by gently pressing together its 
internal surfaces. 



Which of these, it may be asked, is the more favourable condi- 
tion for healthy adhesive repair, quoad the artery ? 



The ligature excites, promotes, 
and prolongs suppuration. 



The ligature, necessarily causes 
ulceration of the artery, and 
death of the part on whidi it is 
tied. 

The ligature remains for an 
indefinite time, and on the other 
hand, from a brittle or slough- 
ing artery, it may be cast off too 
soon. 

The ligatures project between 
the edges of the integument, pre- 
senting a mechanical impediment 
to their union. 

In the application of the liga- 
ture, the vital connexions of the 
artery are damaged, and its vasa 
vasorum broken up. 



The wire has no tendency of 
this kind, hence will there be less 
danger of pvsemia, and a greater 
chance of adhesion of the wound. 

The wire has no such effect ; 
hence, secondary hemorrhage 
will be less likely to occur. 

The wire is removable at will, 
and at the same time it cannot be 
spontaneously dislodged. An- 
other safeguard against bleeding. 

The wire does not interfere 
with the edges of the wound, nor 
with the adjustment of flaps ; 
hence, union by adhesion will be 
more probable. 

The wire is applied without any 
disturbance of the artery itself, 
which, therefore, is probably 
earlier and more securely closed. 



1864.] AS A SUBSTITUTE FOR THE LIOATUBE. 219 

The removal of the ligature is The wire is withdrawn at 

nncertain ; ineffectual attempts once^ and certainly without any 

are common, very painful, and futile, painful, premature trao* 

injurious to reparative action ; tions^ or disturbtmce of parts, or 

and the knot especially, in its any mterruption to the healing 

withdrawal, tears through granu- process, 
lations and breaks up c^esion. 

Of these advantages, some appertain equal! v to the needles, long 
or short, but the wire alone combines them all. It is, at the same 
time, free from the chief defects of acupressure, and in most cases 
will be found by far the most simple, manageable, effectual, and 
satisfactorv method of applying the principle of metallic compree^ 
eionj any form of which is preferable to a ligature. 

P. 8. — Since the above paper was written, I have used the wire 
compress in two other cases, viz., excision of a testicle, and exci- 
sion of a breast. 

The testicle was veiy large from sero-cystic disease, the scrotum 
being also greatly distended by hydrocele, so that the wound was 
fiilly eight inches long. Two arteries in the cord-^which was 
healthy — were secured by two separate wires, fixed, one on each 
side of the incision. They were not disturbed till tne fourth day, 
because the pieces of cork seem to assist in keeping the edges of 
the wound in apposition. The case did well ; the suppuration was 
slight, and the liealing rapid. 

The breast was affected with cancer. A cut had been made into 
it a few weeks before I saw it, in search of pus. From this wound 
a fungous growth was sprouting exuberantly. The incision for its 
removal was six inches long. Three artenes bled ; none of these 
were deep-seated, and they were readily secured by the wires. 
These were all removed in twenty-four hours. For some days 
there was a considerable oozing of the liquefied fat ; but the sup- 
puration was very trivial, and in ten days the cicatrix was firm and 
the cure complete. 



Article IV. — On some Cuatoms of the People of Old Calabar 
relative to Pregnancy and Parturition. By Archibald Hew AN, 
L.B.C.S.E., Medical Missionary at Old Calabar. 



(Bead he/are the OhMrical Society, 8^ June 1864.) 
The paper that I have before me refers to some of the customs of 

theOld , . .. . vM.._.._^ ,_.. ^.r. 

ceeding 



the Old'Calabar people relative to childbearing ; but, before pro- 
ding to the reading of the paper, I should mention how it is 



VOL. X.— HO. in. 2 P 



220 MR HEWAN ON SOME PECULIAB CUSTOMS OF [SEPT. 

that I have the honour to stand here before you this evening. In 
a communication that I had from Professor Simpson lately while 
in Old Calabar, containing instructions regarding a patient of his 
out there, he requested to know something of the customs of that 
people in pregnancy and |)arturition. I made a few notes, there- 
fore, and handed them to him the other day; but, instead of taking 
them, he suggested that I should come here and read them to your 
meeting this evening. To that proposal I hesitated to consent, as 
the notes were so few that it seemed to me like making game of 
the Society to stand up to read them ; but as Dr Simpson urged 
the matter, I could not resist him. 

On thinking over the matter since, it occurred to me that it 
might not be uninteresting, nor perhaps altogether out of place, to 
add a few notes, by way of enlajrgement, relative to the customs of 
the women before pregnancy, and the treatment of their children for 
some time after birth. 

The betrothal of a Calabar female (among the upper classes) takes 
place for the most part very earlv, sometimes so soon as within a 
few days after its birth, — ^and this betrothal is not necessarily to a 
young man of a corresponding age, but rather, and very commonly, 
to a man who is abeady a father of a family, and a husband of 
many wives ; and by no means unfrequently is it to a greyheaded 
grandfather. I have thus seen a strapping man, in the prime and 
vigour of life, dandling on his knees and kissing a baby some two 
or three weeks old that he expects to become his wife, and mother 
of his children, some fifteen or twenty years after. Pointing to her, 
he says, " You see my new wife." The poor little thing is thus, 
willingly or not, made over to him — "diwAerf" to him, as he says. 
He in turn '^ dashes " it many little things, comes now and then and 
nurses it, is entertained by its prattle, watches over it, and fulfils 
in great measure the part of a guardian. The child gets to know 
him, and perhaps to tove him (they learn early to know each other^s 
temper), and when she grows up and becomes his wife, she calls 
him Fciher. The iexm jaiher is the common one given by Calabar 
wives to their husbands. The presents which the guardian-husband 
makes to the child-wife constitute in a great degree a part of the 
marriage-contract, so to speak, which the father and the mother 
dare not break without being liable to Egbo law, — paying back 
every item of present that may have been given, and a great deal 
more ; which is sure to be demanded by the bereaved husband. 

At about the seventh or eighth year, the process of fattening for 
marriage begins. For this there are at least two periods, and some- 
times three. The little girl is taken away fix)m the town to a 
plantation or farm. There she is placed under the care of some 
experienced woman, whose pride and anxiety it is to give her new 
charge a development and form creditable among her sex. She now 
dwells in a darx apartment, and is daubed fix)m head to foot with a 
thin paste made of clay, or marl and water. This chokes up the 



1664.] THE PEOPLE OF OLD CALABAR. 221 

poresy and aa she is not permitted to exert herself in any way. she 
never perspires. It is said, moreorer, that the clay keeps the ooiy 
cooL For foody she has placed before her constantly a large 
supply of yam and plantain oeaten soft like mashed potatoes ; and 
as sne has nothing else to do, she amuses herself by making out of 
this mass balU of a conyenient size for swallowing. This she does 
between the palms of her hands, dips them into a kind of soup in 
which palm-oil predominates, swallows them one by one, never 
chewing, but bolting them as one would do a pill. After she has 
taken a number of them, she takes a few mouthfuls of water, which 
helps to fill up the interstices. A certain q^uantity of food must be 
taken every day, or she is punished. Having reached the desired 
dimensions, she is washed, and decorated with beads and a thick 
roll of worsted around her loins, and is taken to call on her husband 
and her friends, who congratulate, her on her development and 
beauty. The roll of worsted alluded to is her only covering. It 
extends all round the loins, is from two to three inches in diameter, 
and is made out of Kilmarnock night-caps of various colours teasea 
down and twisted. They make the different colours harmonize 
very beautiftdly, and viewed abstractly, one would say it was a 
very pretfrf dress. 

This being over, she is allowed to go freely about again for a few 
years, living now mainly among the wives of her future husband. 
She soon loses all her lately acquired ftilness and bloated appear- 
ance, and becomes quite mmble and healthy-looking again. But 
now comes approacning womanhood. The mammae be^n to en- 
large, and the catamenia appear. This ftmction being fairly estab- 
liahed, she is brought under an operation — a surgical one — namely, 
amputation of the clitoris. The instrument used is a common 
razor, and the operator is a woman. Here I may state, by way of 
explanation, that no man except the husband dares touch or come 
near a betrothed or married woman, not even to shake hands, — ^a 
thing not known between the sexes. Hence the women are the 
chief surgeons ; they practise the art freely upon either sex. whereas 
the man can onl^ practise it upon his own. As to tne modus 
operandi of removmg the clitoris, I am sorry that I am unable to say 
anything, never having been fortunate enough to see the operation 

Grformed. For the most part it is done out of the town. Once I 
d what I thought a good opportunity of seeing it, but the young 
lady heard that we were to come, and her native modesty rebelled ; 
80 that ere a medical friend and 1 arrived it was all over. All that 
we were permitted to see was the instrument — the razor — flying 
beside her. 

Heomorrhage does not, so far as I am aware, frequently attend 
the operation. I know only of one case. I was called out of 
church one Sunday by a guardian-husband to ffo and check the 
bleeding which haa resulted from an operation of this kind. The 
operation had been performed in the morning, and the oozbg had 



222 MB HEWAN ON SOME PECULIAR CUSTOMS OP [SEPT. 

continued all day at an unusual rate ; but, unfortunately for me, ere I 
arrived, they had applied some powerful styptic, and the bleeding 
was stopped. I was not permitted to see it, but they consoled me 
by saying they would send for me if it gave way again. 

This process of cutting off the clitoris is common to all young 
women, whether betrothed or not. If not done, it is looked upon 
as a great disgrace ; and she loses caste among her sex. So also 
is the want of circumcision regarded among males. And separation 
of husband and wife has taken place when, after marriage, tne want 
of the corresponding operation was discovered in the one or the 
other. 

After this operation the great and final period of fattening com- 
mences that is to usher in the nuptials. The young woman is 
again taken out to the farm, and there she goes through a course 
similar to the first one, somewhat more severe and of longer dura- 
tion. She is again covered over with the chalky paste, and she 
eats and drinks incessantly. If the development of the mammsB 
has not taken place sufficiently by this time, it is assisted by means 
of the cupping gourd. She now soon begins to fatten and to bulge 
out: her abdomen enlarges; about the loins and waist are seen 
thick convoluted folds ; and the eyes begin to disappear under the 
enlargement of the cheeks. But matters do not always go on thus 
smootiily. It sometimes happens that the constitution gives way 
and breaks down under this rigorous and unnatural treatment, and 
the patient dies suddenly, or what is almost as bad, becomes feeble, 
hysterical, and sickly, ana she is looked upon as spoiled. 

Passing over the ceremonies connected with the marriage, let us 
look at some of their customs in pregnancy. 

The principal signs of pregnancy noticed by them are the suspen- 
sion of the menses, the darkening of the areola around the nipple, 
and a blanched asn-coloured appearance of the face and upper part 
of the breast, with yellowish spots scattered over them. The 
areolar sign is a well known one, and is considered pathognomonic. 
So much so, and so important a sign is it deemed, that one of the 
main objections urged by the men to the women wearing clothes, 
which we try to introduce among them, is that this valuable sign 
would be in a great de^e lost to the public — the common covering 
of a Calabar woman being merely a strip of cloth half a yard broad 
around her loins. 

During the catamenial flow the woman never leaves the house if 
she can help it. She sits during the day on a night-stool with a 
vessel underneath. The usual period is firom three to five days. 
They date the commencement of pregnancy from the suspension of 
the catamenia, and count by lunar months, from one full moon to 
another. 

At the third month they administer medicines, to prove^ as they 
say, the value of the conception. They regard three kinds of con- 
ceptions as disastrous : 1^^, Conception of twins ; 2cf, Conception of 



1864.] THE PEOPLE OF OLD CALABAR. 223 

an embiTO that will die before birth ; and, 3dy Conception of one 
that will die soon after birth ; and so for the purpose of voiding 
these at as esxly a period as thej think that the conception has 
fully taken place, they administer medicines. 

These medicines are administered by the mouth, per anum, and 
per vaginam. By way of the mouth, and bjr enemata, first. If a 
oloody discharge from the vagina follows, it is assisted by an appli- 
cation direct to the oa uteri. For this purpose they employ one of 
three herbs, one a euphorbia, another a leguminosa. and another an 
amomum. The steminal end of the leaf-stalk of the euphorbia, 
with its exuding juice, is pushed up the vagina. On the same part 
of the leguminous one is placed a small quantity of guinea pepper, 
chewed into a mass with the saliva. This guinea pq^per is a species 
of the amomums. In the course of a few days the abortion may 
take place. But it is not abortion pure and simple that is desired ; 
it is conditional, as I have already said. It is only to procure it in 
the case of one of three conceptions, either of which being, in 
their estimation, unnatural, they consider to have little or no nold 
upon the uterus. But it not imfirequently happens that the measures 
employed are too severe: serious constitutional disturbance and 
or^nic lesions take place, and death ensues. 

The seventh montn is regarded by them as a bad one. Many 
abortions are said to take place then. 

As pregnancy advances the woman is generally sent away to a 
farm where she can live quietly and free nrom the excitements and 
bustle of the town ; and more than that, to be out of the reach of 
witchcraft. Barren women, and women who abort, commonly 
attribute their misfortune to the evil eye of some neighoour. 

With reference to parturition: — ^While in labour the patient 
moves about, or if she sits, it is on a low stool or log of wood. The 
midwife squatting before ner with hands oiled, uses steady gentle 

i)ressure on the parietes of the abdomen from above downwards and 
brwards, helping, they say, the child to find its way down. While 
the child is being bom no assistance is given ; it passes out, and is 
allowed to lie between the thighs of the mother till the placenta 
comes away, however long that may be. The funis is then cut 
with a razor, and the child is removed. The mother, very soon 
after, has a large potftd of chop placed before her, which her 
husl)and had b^n Dusy preparing ror her during her labour, and 
she is expected to take a large quantity of it. Around her abdomen 
is tied wnat is meant for a bandage. It is simply a handkerchief 
twisted so as to make something more like a cincture than a bandage, 
and it is placed right over the hard contracting womb. 

The child being removed, is rubbed over with fine sand, after which 
it is washed with soap and warm water. The juice of the fruit of one 
of the amomums, pretty acid, is then squeezed into its mouth, after 
which it gets a supply of tepid water. It is not allowed to suck 
for two or three days, during which time it gets nothing but water. 



224 SOME PECULIAR CUSTOMS AT OLD CALABAB. [SEPT. 

Indeed, water seems to fonn one of the principal portions of its 
support for some time to come. The mother's breast is generally 
redundant with milk, dropping out not unfrequently, and the child 
quite able to suck largely, yet a large quantity of water is given it 
once at least every i&y. Eveiy morning while the child is being 
washed, water is occasionally tnrown into its mouth. This is con- 
tinued for several minutes, during which the child gasps and 
struggles. It is done, they say, to distend the abdomen, and make 
it capacious for afterwards takmg plenty of milk and food to accele-* 
rate its growth. Should the motner be absent any day for a few 
hours, the child is kept quiet by filling its stomach with this cheap 
liquid. They acknowledge its ^reat use in this respect. It is 
a remarkable fact in connexion with the lar^ amount of cold water 
forced into the stomach of their infants that enlargement of the 
spleen is very common among them — ^far more common among the 
infants and children than among those of greater age. 

The period of suckling continues till within a few months of the 
next parturition. This does not generally take place for two or 
three years after the last ; the husband not cohabiting with his wife 
for eighteen months or two years. Sometimes, when no subsequent 
pregnancy takes place, the child is allowed to suck on at his own 
pleasure till he choose to give it up. 

Fruitful wives are reckoned the favourites. Those who do not 
bear give their maidservants to bear for them, and count the ofispring 
as their own. 

In the middle of the doorway of a house, where there has been a 
birth, may be seen a bundle of green leaves suspended by a string. 
This is the way they take to advertise a birth. 

Twins are looked upon as monsters, and are destroyed: the mother 
herself taking the initiative in their destruction. An earthen vessel, 
such as they use for carrying water, is brought to her. She then 
lifts them up one after uie other, and places them in the vessel 
An attendant then carries them out to the woods, and there they 
axe left to perish from exposure, or to be devoured by wild beasts. 
More frequently the voracious ants that go about in large colonies 
find them out, and eat them up in a few minutes. 

Should the mother die in childbed the living infant is buried 
along with her. 

Such are some of the customs of the old Calabar people : very 
curious and very cruel they are ; but I am glad to be able to add 
that they are now being considerably modified and abolished under 
the teaching and influence of the missionaries. 



1864.] RECENT IMPBOVElf ENTS IN OPERATIVE MIDWIFERY. 225 

Article V. — On the BesuUa of Recent ImprovemmU in OpmiHve 
Midmfery in cUminuhing the Number of Caeea requiring jEmbry* 
oUmy. By Andrew Inqlis, M.D., F.B.C.S.£din. 

{Bead htfare the Edinburgh Obstetrical Society, 11th May 1864.) 

In thifl paper I propose to state the efiects which the more recent 
improTements in the method of effecting deliverir in cases of con- 
tracted pelvis, must have had on the proportion between the favour- 
able ana unfavourable results of craniotomy, and then, by reference 
to the previous statistics of the operation, to indicate what its value 
now appears to be. 

The three changes which seem to act most powerfullv in produc- 
ing such an alteration are, — ^the use of chloroform, the improve- 
ments in the form and in the manner of application of forceps, and 
the employment of podalic version. 

The effects of the use of chloroform in increasing the death-rate 
of craniotomy must be considerable, for though it renders the opera- 
tion somewhat easier, and perhaps even safer, still this is not the 
case to such an extent as can materially affect the statistics of the 
operation ; while, on the other hand, its exhibition, by permitting 
tne substitution, in the milder cases of contraction, of a less severe 
method of treatment, deprives craniotomy of a number of the very 
cases which formerly furnished the greater part of its recoveries. 
For in many cases where, without chloroform, craniotomy would 
have been resorted to, the use of that agent, by procuring an early 
dilatation of the soft parts, gives an opportunity for delivery by 
forceps, or, by bringing about the same relaxation, accompanied by 
the suspension of uterine action, enables us to extract by turning. 

While chloroform has thus been doing much to facihtate the use 
of the forceps, great improvements have also been made in their 
form and in the manner of using them. This has not been suddenly 
effected; but the profession has, in course of time, gradually 
become better acquainted with liie shape of the pelvis, and with 
many other points connected with their use, which has not only 
enabled them to use the old form of instruments more efficiently, 
but has also occasioned successive changes in their shape. Tne 
result of these improvements has been not only to increase the 
safety of the operation in the cases to which their use was formerly 
confined, but, in addition, to extend their application to many of the 
less severe cases of contraction then considered to require crani- 
otomy, thus again tending to diminish the favourable results of 
craniotomy in those cases to which its application is thereby chiefly 
confined. 

Podalic version, which has long been employed for other purposes, 
and even suggested at an earlier period in the cases now under 
consideration, has only comparatively recently been much used in 
labour rendered difficult by pelvic distortion. Not only is it, how- 



226 DR ANDREW INGLIS ON RECENT [SEPT. 

ever, now used in many cases in which forceps would otherwise 
have been employed, but it has been performed with success as 
regards both mother « and child, in cases where the deformity was 
too great to admit of their use. 

It was some time affo shown very clearly by Dr Simpson, that in 
many cases of pelvic distortion the child was bom alive when the 
lower extremities presented, while in the other labours of the same 
patients none were saved when the head presented, — delivery 
through the natural passages havine been founa impossible without 
craniotomy. He therefore proposed in such cases always to turn 
and extract by the feet, and the value of this method of practice 
has been fully established by its results; and even when the 
child cannot be extracted alive by this operation, but dies in the 
course of it, or in consequence of additional operative procedure 
being found requisite, the danger to the mother is inconsiderable 
compared with that entailed by instrumental delivery in the natural 
position of the child. 

That the use of version has therefore, in the same way as the 
improvements relating to forceps, and to an even greater extent, 
lowered our estimate of the value of craniotomy, will be at once 
admitted ; though at the same time it may be remarked, that if it 
were prefaced, when possible, by turning, much might be done to 
diminish the mortality in the cases where it is still performed. 

But, in estimating the effect of all these improvements in reduc- 
ing the number of cases formerly held to require craniotomy, we 
must especially take into account that it is only to the milder cases of 
pelvic distortion they are applicable ; and, as the occurrence of the 
more formidable cases of contraction becomes rarer in a ratio which 
increases very rapidly with its increase in degree, a proportionally 
rapid diminution of the number of cases still requiring craniotomy 
must be a necessary consequence ; while the unfavourable circum- 
stances under which it has to be performed must be accompanied 
by a corresponding increase in the^ ratio of mortality attendant 
upon it. 

To enable us to determine precisely the present value of the 
operation of craniotomy, accurate statistics would be required ; but 
as these do not exist, I must instead attempt an approximation to 
the present death-rate by inferring from previously existing statistics 
the probable results of what has now been stated. The previous 
statistics are well known, and the mortality deducible therefrom is 
1 in 4 or 1 in 5 ; therefore, if what I have already stated as to the 
effects of improvement in practice be correct, it will be quite safe 
to assume the present mortab'ty to be very considerably greater than 
1 tn 4 or 5 ; or probably 1 in 3 would not be a rash assumption. 

The next step towards the attainment of a proper appreciation of 
the merits of the operation seems to be the comparison of its results 
with those of other operations applicable to the same class of cases. 
As craniotomy is now confined by the best authorities to cases in 



1864.] IMPBOVEUEKTS IN OPERATIVE MIDWIFERY. 227 

which deliveiy cannot be effected hy means of forceps or turning 
alone^ and as the mortality of these operations is hardly appreciable, 
it is evident that a compNarison between them and craniotomy may 
be left out of consideration, as affording no criterion for such an 
estimate as that at which we wish to arrive ; but with Canarean 
section the case is different, for although at present it is true that 
that operation (in consequence apparently of reliance on old statis- 
tics) is considered justifiable only where craniotomy cannot be per- 
formed with success as regards extraction, the aifferenoe in the 
mortally is, I believe, by no means certainly in favour of 
craniotomy. 

With regard to the CaBsarean operation, we are now in a much 
better position to obtain success than we were a few years ago ; 
and I believe there is a paper by M. Dufeillv on the operation, in 
which he has collected the statistics of all the cases performed 
since 1858, and shows that, where the operation has been nerformed 
with or^nary care, at the proper time for interference, ttie results 
have been about 75 per cent, of recoveries, that is to say, 1 death in 4. 
being not much more than the result of craniotomy as performea 
under the old regime, and consequently in all probability more 
favourable than those of the same operation, limited in its applica^ 
tion, as it may now be said to be, to a small number of cases of a 
very unfavourable description. There is another point also to be 
noticed in favour of Csesarean section. In this country we have 
improved rapidly of late in the performance of ovariotomy, — ^an 
operation very similar in many respects, but having adaitional 
complications of a serious character; and, if we can produce 
by it such &vourable results as one death in four, where, by 
enormous incisions and dissections, we remove from the abdomen 
a part of the frame itself, and are under the necessity of leaving 
benind much that must separate by suppuration, how much 
more success oueht we to expect, in removing from the same 
cavi^ a foreign body, without oeing obliged to make such exten- 
sive wounds, and not necessarily having to leave behind any- 
thing to slough away. Besides, if we examine the individual 
reports of cases of Cesarean section, we shall find, on the one hand, 
that in many of the fatal ones, setting aside the question how long 
the patient had been in labour, the operation had been so ill done 
that death could not fail to ensue ; and, on the other hand, that 
among the recoveries there were some where it had been so badlv 
done, as almost to put a favourable result out of the question, leaa- 
ing us to infer that on both these accounts, if due care haa been 
taken, a much higher success might have been attained. 

Since writing the above, I have heard that Dr Tyler Smith has 
written a paper advocating the abolition of craniotomy, but I am 
sorry I have not yet had an opportunity of perusing it so as to con- 
sider his objections, many ot which must be the same as those 
now brought forward ; but I am glad to hear that I do not stand 

VOL. X.— NO. m. 2 Q 



228 DB ANDBEW INGLTS ON REGENT [SEFT. 

alone in questioning the correctness of the value at present iisually 
put upon the operation. 

From the foregoing it will be apparent, that unless something 
considerable can be done to render craniotomy a less fatal operar 
tion than it is at present, Cassarean section must prove, at least, a 
formidable rival. I have already stated my belief that a good deal 
might be done in this direction for a certain class of the cases held 
to require craniotomy, by the use of turning as a preliminary to the 
operation ; but as, after deducting these, there would still be left a 
great many cases, with a mortality certainly even greater in propor- 
tion than that of the whole number in which craniotomy is at present 
performed, it would become only the more incumbent on us to see 
if we should really be justified m preferring it to Cadsarean section 
for the cases where turning cannot be e&cted <m account of the 
narrowness of the pelvis alone. 

The best form m which I can express my views as to the value 
to be assigned to craniotomy, seems to be the suggestion of rules 
for its employment ; but before attempting this, it may be as well to 
consider tne nature of the rules at present generally accepted. 

At present we have a tolerably sufficient knowledge of the indi- 
cations demanding interference of some kind, but the limits beyond 
which the different operations ought not to be attempted are so 
variously laid down, as to give rise to much confusion. The 
principal ^de given for the treatment of such cases is the minimum 
number of inches in the different diameters of the pelvis through 
which a full-sized child can be extracted, — in one case by means 
not necessarily destructive to it, and, in another, by means in prin- 
ciple involving its destruction. This guide is obviously unsatis- 
factory, for it IS hardly possible to get any two men to agree as to 
the measurement in inches of the brim of the pelvis in a patient ; 
and, moreover, there are great differences of opinion as to the exact 
measurement required to decide which operation ought to be 
attempted in any given case. Then these measurements are laid 
down without reference to the probable size of the child, which, as 
we know, may vary in weight from six to twelve, or even fourteen 
pounds, at the full time. Besides, its consistency may also alter 
the prospect of the case most seriously. We have also another 
source of dissatisfaction in dealing with this operation, viz., the 
possibility, if the result be successful, of a doubt remaining as to 
whether a milder method of interference might not have been at 
least as safe ; and we never can be so sure after such a success, 
as we are in most otlier surgical operations, that we have adopted 
the best possible means. 

I shall now merely, in conclusion, give the rules to which I 
have been led by personal observation of cases of labour rendered 
difficult by contraction of the pelvis, combined with the study of 
published reports of individual cases of the kind. 

Istj In all cases where the indications for interjerence are suffidenJt^ 



18Gi.] IMPBOTEMBMTB IN OPEBATITE MIDWIFERT. 229 

the forceps should be applied, provided there is a reasonable chance 
of their being Buccessfm without injuir to the mother* 

2d, Shaulaforcq>8 be Jbund unsuiUwlej recourse should be had to 
veision. even though the extraction of the head with instruments be 
afterwards it^quiied. 

3df Should the pelvis admit cf turning, but be too small to allow 
the extraction of the body, we ought seriously to consider the ad- 
yisabililT of Cossarean section. 

4th, ahauld the pelvis he too small to admit of turning, the argu- 
ments in favour of Caesarean section must be still stronger. 

I have divided the cases included in the last two rules into two 
sets, one where turning is possible^ and the other where it is impos- 
sible, because, I believe, that such a means of distinction is better 
than the old rule by measurement in inches; and I have not 
insisted on Csesarean section in the former of these cases where 
turning was found possible, because I have heard of the head having 
been re-turned ana craniotomy having been performed on it " in 
situ," but with a fatal result, and it is possible (though improbable) 
that some successful precedent may nave given nse to such a 
method of practice. 

The whole of these remarks on craniotomy have been made with 
reference to the size of the pelvis alone, and though I have said 
much in disparagement of the operation, still I admit that there 
are exceptional cases, where, from the state of the uterus or some 
other cause, it appears to be inevitable. 

There is another point I have not taken notice of, viz., the value 
of the life of the child. I have not done so because, though I 
think it might be an additional reason in favour of Ceesarean section, 
still it cannot at amr time be compared with that of the mother, so 
as te materially influence our decision, where there is a more rea- 
sonable hope of preserving the latter by adopting other means ; but 
wherever m any individual case we come to toe conclusion that 
CsBsarean section gives to the mother a chance of recovery equal to 
that afibrded by any other means that can be adopted, then the 
additional chance of saving the child becomes an important element 
in determining our choice. 



Article YL.— Cosmic Sensibility. By David Leslie, M.D., 
Tunbridge, Kent. 

''SensibiUty is the nonl of the world.'' 

From the vibration of the magnetic needle to the perturbation of a 
planet, it is sensibility that acts, producing phenomena and generat- 
ing forms. Sensibility is physical and vital.^ Vital sensibility 
naturally divides itsetf into organic and conscious. But at what 



230 DR LESLIE ON COSMIC SENSIBILITY.. [SEJPT, 

period physical sensibility became vital, or on what link in the 
chain of nature the Promethean fire of life first fell, is as yet un- 
known. At what point in the animal scale of bein^ consciousness 
first began, is equally involved in mystery. Neither can we dis- 
cover exactly when consciousness commences in the period of indi- 
vidual development, for no one pretends that consciousness is 
possessed by the earliest forms of life even in the highest order of 
inteUectual beings? At what period then does it begin? When 
did conscious sensibility first exist ? Physical sensibility is chemical 
and dynamic Chemical sensibility is manifested only on contact, 
by phenomenal manifestations called behaviour, thus using a moral 
idea to express a physical fact. However mysterious chemical 
attraction may be, and however inexplicable the preference some 
elements show for others, with a fidelity that never changes, the 
fact that matter is sensible of the presence of matter at immense 
distances is still more wonderful. Matter manifests consciousness 
of the presence of matter from the insensible distance that measures 
the range of chemical affinity to the almost incalculable distances 
of fixed stars, producing a uniformity of phenomenal successions 
called laws. Matter is nowhere inert, never in repose. It is 
always sensible of the existence of other portions of matter, although 
at the opposite extremes of the visible universe. Matter manifests 
sensibility to the presence of matter from the closest proximity 
to the most remote regions of space ; from our solar centre to the 
uttermost verge of the known universe, to the very threshold of 
infinity. 

That matter should be sensible of the existence of matter althouj^h 
millions of miles apart is quite inexplicable. Can this sensibility 
manifest itself although the subjects be separated by an absolute 
void? What is that power that traverses a void, the space so 
traversed being still a void? Yet, such seems to be attraction. 
Can that be called a void which contains something? for something 
must pass from one planet or star to another to make them mutually 
sensible of their existence. What is this messenger? Can it pass 
through a void, and the space traversed remain a void ? If nothing 
pass from planet to planet, or from star to star, how is their sensi- 
fcility excited? Whatever this medium of intelligence from star to 
star may be, it is always imiform in its action. Matter behaves 
with matter {se comporte) invariably in the same manner under the 
same conditions. It obeys laws which never change, which are 
called physical. It is to the permanent and unchangeable nature 
of these laws that we owe physics, t.€., natural philosophy. In fact, 
natural philosophy is nothing more than the record of the imchange- 
able and fixed laws of the material universe, which is the foundation 
of every thing implied in the word science. Laws being nothing 
more than uniformity of succession, if that succession was liable to 
interruptions or changes, we coula no longer calculate on the cer- 
tainty of physical events ; science would cease to exist, and man 



1864.] PB LE8UE OH COBMIC SEMSIBILITT. 231 

must inevitablj perish. The words skill, cantiony foresi^ht^ etc«| 
would then have no existence. Faith in tne invariable unifonnitVi 
in the order of phenomenal successions, is almost a religion with the 
philosopher (the high-priest of nature) , for it admits of no scepti- 
cism, ifature never deceives ua. Our errors can only exist in 
words, for the order of phenomenal succession, that is, natural law, 
never changes ; if it did, science could exist no longer. Sensibilitj 
admits of being divided into two kinds, phvsical and vital. Phy- 
sical sensibility is displayed in gravity, electricity, and chemical 
affinity. Vital sensibility is manifested in idl the phenomena of 
organic and moral existences. This classification, nowever, like 
most others, is merely arbitrary, for the transition from material to 
vital phenomena is so imperceptible as to be as yet unascertained. 
On what link in the great cham of existences the Promethean fire 
of life first fell is as yet a secret to naturalists. Where is the point 
in the scale of nature where vitality commences, and what is this 
new property called life which thus seems to be added to matter? 
Spontaneous generation is still only a theory, and whether matter 
of itself possess the powers under certain conditions of assuming 
organic and vital forms, or whether vitality be a specific creative 
addition to matter, is a question as yet undecided. Matter itself is 
the unknown cause of the union of Qualities. That vitality should 
be a quality, united to matter, manifested only under certain condi- 
tions, is no greater mysterv than gravity or chemical attraction. 
'^ Sensibility is the soul of the world." It may be used in this 
universal sense with propriety. In fact, the expression can scarcely 
be called figurative. 

Sensibilitjr causes motion. There may be change of place, that 
is, motion, without change of form, but change of form cannot occur 
without change of place. Physical sensibility generates automorphic 
forms which never change under the same conditions. '' Such as 
creation's dawn beheld," we see them now. Common salt always 
crystallizes in cubes, quartz in six-sided prisms, etc. One part of 
hydrogen combines always with eight of oxygen, sixteen of sulphur, 
etc., etc. These are essential elective and morphic characters that 
never change. 

Vital sensibility is geneomorphic, not automorphic, as physical 
sensibility is. If vital sensibility be automorphic, then the doctrine 
of spontaneous generation is true. 

Vital sensibiUty produces geneomorphic forms. It is divided 
into two kinds, organic or unconscious, and moral or conscious sensi- 
bility. Firsty We nave physical sensibility, such as ^vity, chemical 
affinity, and electricity. Second^ Vital, which is divided into organic 
and moral. 

Organic sensibility exists in the yital world up to the unknown 
point where consciousness begins. But at what link in the chain 
of animated beings consciousness begins, we know not. From man 
to the amoeba, where is the point wnere the consciousness of entity 



232 DE LESLIE ON COSMIC SENSIBILITY. [SEPT. 

ceases^ where the / am exists no longer? In erowth development, 
from the zoosperm to mftn^ &t what exact perioa does the conscioua* 
ness of entity bejgin? This particular point in the progressive 
scale of physiological development is quite unknown. Is there a 
hiatus, a chasm, between organic and moral sensibility, that is, 
between unconscious and conscious vitality? No such breach in 
the chain of organic development has been discovered ; hence the 
difficulty of classification wnich can only represent distance in the 
scale of life, but not difference. 

Physical sensibility produces automorphism. Particles of matter 
possess in themselves that mysterious morphic power which moulds 
and shapes the superficial aggregation of atoms, giving them de- 
finite forms that never change. It is to this inherent power pos- 
sessed by matter that I apply the term automorphic. 

Vital sensibility determines organic and moral forms, which are 
not automorphic. They are generated by a power called vital; 
hence the term geneomorphic, m opposition to automorphic. The 
one purely physical, never changing; the other vital, always 
changing. Moral forms are the results of volition determined by 
the excitement of emotionary sensibilities, such as a chair, or a 
watch. A crystal, a flower, and a house, represent physical, organic, 
and moral morphisms. Moral selections, moral causation, depend 
on the emotionary susceptibilities. They are the resultants of the 
several emotionary attractions, the unity of which is choice. 

Emotionary. that is, moral causation depending on such varied 
moral susceptibilities, must produce varied and different effects, 
manifested by different volitions, and, therefore, resulting in different 
acts. Hence the same external or internal moral cause will produce 
different effects when acting on different emotionary susceptibilities. 
An innocent act from certain training and education of the emotionary 
susceptibilities may be thought highly criminal, such as eating 
pork, etc., etc. From the same causes, what to one would appear 
a justifiable death, would be by another murder. The moral or the 
voluntary act is the effect of natural causes like a physical pheno- 
menon. It is the resultant of emotionary and reflex moral powers 
of which the agent is the emotionary cause^ called volition. 

The emotion that decides the vobtion is mdependent of the moral 
being, uncreated by him, an essential property of his entity, and as 
necessary to his specific identity as attraction to matter or form to 
a crystal; the cause being purely cosmic, and not individual in 
either case, and therefore only a link in the great chain of universal 
causation. 

Sensibility is the generative cause of all phenomena. It is a 
name for an unknown agent seen only by its effects. Our planets 
would manifest strong emotion at the presence of a stranger in their 
system. Even their changes of place give rise to what are called 
perturbations, the result of cosmic sensibility. Potassium is greatly 
excited by the presence of oxygen, for even when thrown on water 



1864.] DR LESLIE OV CO0MIC 6EN8IBILITT. 233 

it ignit»L The needle manifesto great sensibility to the presence 
of me magnet 

Organic tissues manifest great sensibility to the presence and 
contact of certain substances which it seems is quite independent of 
dynamic or physical action. A grain of tartar-emetic produces a 
greater physiological and dynamic effect on the animal system than 
an ounce of cha&. No reasoning h priori would have foreseen this 
result, so ignorant are we of vital and physiological laws. Certain 
poisons act on one class of nerves^ otners on a different class of 
nerves. So remarkable is this fact, that one pupil can be con- 
tracted and the other dilated at the same time by different toxic 
agents, as by belladonna, and the Calabar bean. 1 had once under 
my care a case of aneurism of the arteria innominata^ accompanied 
with mydriasis of one eye. The mydriasis was evidently in this 
case produced by excitement of the cervical sym^thetic from pres- 
sure of the aneurismal swelling. By thus irritating the gangbonic 
extremities of the nerves that supply the radiating fibres of the iris, 
the harmony of the physiological antagonism between the third ana 
sympathetic nerves was deranged ; the circular fibres supplied by 
the third pair of nerves yielded to the increased power of the 
radiating nbres supplied by the sympathetic, and thus dilation of 
the pupil was produced. This was a very remarkable case of 
patholo^cal organic and unconscious sensibility. Certain organs 
are sensible only to the action of particular substances. The salivaiy 
glands are extremely sensible to the presence of mercury, the kid^ 
neys to alkalis, the conjunctiva to ars^c. The vapour of tur^n- 
tine, even its odour, gives to urine the perfume of violets ; cantharides 
acts on the urinary organs, etc., etc In the scale of what is called 
progress or development, we pass from physical to organic sensibility, 
and then to conscious or moral sensibility. At what period in the 
scale of vitality, emotionary sensibility, or consciousness commences, 
we know not. This is a ^eat mystery, nor is it possible we can 
ever know what that conscious entity is, the I, of the I am, for then 
the I would be both the subject and the object at the same time* 
We have then physical sensibility generating automorphisms, as a 
crystal; organic sensibility proaucing vital forms, as a flower; 
emotionary, that is, moral sensibility, giving rise to moral acte and 
constructive or rational forms, as a watch, or a house. 

Moral morphisms and moral acto are tne results of reflex action, 
from external or internal causes, acting on the vital and conscious 
organization. The morphic creations of man, and his moral acts, 
are the effects of causes mdependent of him, as much as the growth 
of a plant, or the form of a crystal, is not the effect or act of any 
volition in the plant or crystal. Moral power cannot create, it obeys 
the laws of cause and effect, like physicBil power. Vital sensibility 
produces phenomena inexplicable by dynamic laws; that is, the 
uniformity of the succession of vital phenomena is not in accordance 
with the uniformity of succession of dynamic or physical phenomena. 



234 DR JAMES WATSON^S CASE OF ALOPECIA AREATA [SEPT. 

Physical forms are automorphic : the crystal never changes. Vital 
forms are geneomorphic : the result of conjugation, even in the 
elementary cell. But at what point automorphism passes into 

Seneomorphism, it is impossible to tell. When unconscious sensi- 
ility passes into conscious sensibility, is equally a mystery. Is 
then volition reflex, automatic, without consciousness? The voli- 
tion by which the amoeba protrudes its gelatinous processes, is it the 
same as that which guided the pencil of Raphael, or the pen of 
Laplace? If it differs, at what period in the scale of vital progress 
dia this difference begin? We can find no hiatus, no point of 
differential volition, except in degree, throughout the whole chain 
of animated beings. 



Article VII. — Notes of a Case of Alopecia Areata treated by 
Carbolic Acid. By James Watson, M.D., Edinburgh. 

In a former number of this Journal,^ I drew attention to some 
experiments and observations I had made with several new drugs. 
One of these was carbolic acid. Since publishing the paper referred 
to, I have used carbolic acid for several purposes, and with apparent 
advantage. The success which attendea the treatment of favus, by 
carbolic acid, in one of Professor Bennett's Wards, and which I 
recorded, has now been attained by other medical men in this city, 
who have since tried it in the same disease ; and there seems every 
reason to believe that it will act as a powerful agent in destroying 
parasites in other skin affections. I am not aware that carbolic 
acid has been tried in the treatment of psoriasis ; but think, where 
the local application of pitch ointment has been so successful, 
carbolic acia, one of its essential ingredients, will in all likelihood 
be found equally useftil. Should this be so, the application will be 
more easily used, less disagreeable to the patient and the patient's 
friends, and well adapted for private practice. 

Before recording the case of which I am about to give the notes, 
I wish to draw attention to a use, to which, from some trials I have 
made with carbolic acid, I think it might with advantage be put. 
For a long time creasote has been used by medical men, dentists, 
and the public generally, to allay toothache, with more or less 
success. Dentists now use it principally, I believe, for cleaning 
out the carious cavity of a bad tooth. It is for this latter purpose 
I would suggest the substitution of carbolic acid. The two sub- 
stances are very nearly allied ; but while pure creasote is difficult to 
prepare, and rarely to be obtained, pure carbolic acid can be got 
from any respectable chemist. From a good many experiments I 
have made with the two agents — creasote and carbolic acid — I am 
strongly inclined to think the latter the more useful application in 
^ January 1864 : Observations on some New Medicines. 



1864.] TREATED BT CARBOLIC ACID. 235 

destroying and causing the separation of the carions matter in the 
cavity of the tooth. In my own experience I never found creasote 
allay toothache. I have now repeatedly found carbolic acid do so. 

With these preliminary remarks I shall now give the notes of a 
case of alopecia areata treated by carbolic acid. 

In the first week of January 1864, M. H., set. 28, came to Ward 
12, Boyal Infirmary, to consult Professor Simpson about a uterine 
disease under which she was labouring. At this time patient 
looked weak, under-nourished, and was intensely nervous. After 
attention haa been paid to the more immediate object of her visit, 
it was noticed that patient's head was completely bald, with the 
exception of a few stray, long, dark hairs scattered over it. On 
more careful examination she was found to be suffering from incip- 
ient phthisis. On making inquiry as to her antecedents, we made 
out tne following — 

ERstory. — ^Until M. H. got married, ten years ago, she had alwavs 
enjoyed good health and strength (unless at her monthly periods, 
when she suffered from dysmenorrhoea), and was in the habit of 
attending to all the household duties of a &mily of eight brothers, 
without experiencing fatigue. About three months after her 
marriage she witnessed a wrestling match between two of her 
brothers on the green. The elder of the two was the stronger, and, 
as patient says, easily excited. Fearing that he was losing temper, 
ana that he might hurt the younger brother, she rushed between 
the two, in order to separate the combatants. In so doing she fell 
and brought down the two wrestlers on the top of her, and was 
crushed in the lower part of the abdomen. That night patient, 
who was about three months pregnant, aborted, with severe flood- 
ing, which untoward circumstance she attributed to the fright and 
injury she sustained in the scuffle. From this date, although 
patient continued to menstruate regularly, the catamenial flow was 
less than formerly, although it had always been scanty. This state 
of matters continued till the month of August 1862, when patient 
ceased to menstruate altogether ; since which date she has suffered 
from amenorrhcea. 

Last December (1868), patient suffered from a severe attack of tic 
douloureux in the crown of the head. Synchronously with this 
attack a small patch of the scalp became bald. Dr Alex. Simpson, 
who saw patient in her own house at this time, painted the bala 
portion 01 the head with Smith's blistering fluid, m the hope that 
this treatment would both relieve the pain and limit the baldness. 
But although the tic douloureux was relieved, the baldness extended 
and became complete in spite of the repeated applications of the 
blistering fluid. 

It was at this time (beginning of January 1864) and in this con- 
dition, the head bald from ear to ear, and from the brow to the 
back of the neck (with the exception of the few dark hairs already 
mentioned, which seemed to indicate the points where the several 

VOL. X.— NO. m. 2 H 



236 DR JAMES WATSON'S CASE OP AfiOPECIA AREATA [SEPT. 

round bald patches coalesced) .that patient came to the hospital to 
consult Proiessor Simpson. The scalp was well nigh covered with 
a yellow favus-like crust, caused by the use of the blistering fluid. 
Professor Simpson having prescribed for the uterine affection under 
which patient was labouring, I asked his permission to try the 
effect ot carbolic acid in the affection of the scalp. He at once and 
very kindly acceded to my request. 

The treatment indicated was both constitutional and local. 

Constitutional Treatment. — As patient's constitution was feeble 
and oppressed I ordered her citrate of iron and quinine, dissolved 
in infusion of calumba, cod-liver oil,^ wine, and good nourishing 
diet. 

Local Treatment. — As the scalp was nearly covered with a crust, 
the result of the free use of blistering fluid, I got the head poulticed 
for two or three days. When the crust was removed the head had 
a somewhat oedematous look, otherwise it had all the appearance of 
a head bald from age. There were several patches of the scalp 
slightly reddened. I now began the application of carbolic acid 
dissolved in glycerine, in the proportion of one drachm of the acid to 
three ounces of glycerine. The lotion was applied night and morn- 
ing ; and, to prevent it evaporating, a cap made of oil-silk was con- 
stantly worn. The head was washed morning and evening, before 
the lotion was applied, with black soap and water. 

Besult of Treatment. — Under the constitutional treatment patient 
soon began to improve in appearance, and her general aspect 
assumed a healthier and happier character. The cheeks, which 
were formerly sunk, became full and nlump, and the lips, once 
white and blanched, red and life like. This change, however, was 
not immediate, but the result of eight or ten weeks^ treatment 

The local treatment by carbolic acid was conmienced about the 
12th day of January. The first result observed was the disappear- 
ance of the oedema of the scalp, and a freedom from the uneasiness 
in the head, which succeeded tne tic douloureux, and continued to 
annoy patient till the lotion had been used for about two weeks. 
It was next noticed that the slightly crimson patches of scalp 
became pale, and the whole scalp white. The few hairs scattered 
over the scalp had now fallen out; and from ear to ear, and 
from the brow to the posterior aspect of the neck, there was not 
a single hair on the head. For a month after the lotion was 
used there was a slight frirfuraceous desquamation of the scalp. 
At the end of six weeks from the commencement of the local treat- 
ment, the head was still quite bare, and it was only by the aid of a 
magnifying glass that it was possible to recognise openings in the 

^ Patient could not take the cod-liver oil supplied to the hospital, as it 
deranged her stomach, and made her generally vomit her food. In this case, 
as in several others, I prescribed, instead of the ordinarjr oil, a preparation 
called " Furley's cod-liver oil cream," which patient took without inducing any 
disagreeable symptoms, and with decided advantage. 



1864.] TREATED BT CABBOLIC ACID. 237 

skin which commimicated with the fine canals leading to the hair 
bnlbs, and distinguiBhed this head iirom the baldness due to age. 
At the end of February, a crop of very fine, silken, white hair 
made its appearance over the wnole scalp. It was perfectly free 
firom pigment, resemblinj?, yet differing from the hair of new-bom 
children. At the end of March, the hair was about an inch long 
over many parts of the head, the white character of which gave to 
the otherwise young appearance of jthe patient a most peculiar 
aspect. The lotion was continued morning and evening till the end 
of June, since which date the local treatment has consisted solely 
in washing the head, night and morning, with black soap and water, 
and the free use of a brush to the surface of the head three or four 
times in the course of the day. 

Patient left the hospital on the 3d day of August 1864, with the 
scalp in perfect health, and with a covering of fine, glossy, silken 
hair, now very slightly tinged yellow, and measuring firom one and 
a half to two inches long. 

Bemarks. — ^This case is interesting, inasmuch as it is, I believe, 
the first treated by carbolic acid. It is worthy of note that while the 
hair, which was very plentiful, fell out, and in the course of fourteen 
days left the scalp entirely bare, the patient had not suffered, as 
eenerally occurs in these cases, at or about the time firom any acute 
rever or inflammatory attack. The alopecia areata, although so 
complete as far as the head was concerned, was confined to the 
scalp; the eyebrows, eyelashes, hair over the pubes and axillsd 
remained intact. Although in this case I dissolved the carbolic 
acid in glycerine, it may be sometimes preferable to dissolve it in 
acetic acid; and when glycerine is used as the solvent, it may 
occasionally be wise to make the lotion considerably stronger. 



Article VIIL — Fourteen Cases of Ovariotomy. By Thomas 
Keith, F.II.C.S.E. 

{Continued Jrom p. 153.) 

Case VII. — Cystic and Adenoid Ovarian Tumour. Ovariotomy. 

Recovery. 

In March last, Dr Drummond of Glasgow asked me to see a lady 
who had come under his care two months before, on account of 
ovarian disease. She had enjoyed good health till the autumn of 
1861, when she suffered from attaciS of diarrhoea. During 1862, 
she had violent and repeated attacks, and was then put upon a diet 
consisting chiefly of iHsef juice, and upon this she has since con- 
tinued principally to live. In January 1863, the lower extremities 
began to swell, and for the first time she felt her dresses tight upon 



238 CABEa OP OVARIOTOMY BY DB KEITH. [BEPT. 

her. She again had diarrhoea in the autumn of that year, and in 
September had an attack of menorrhagia, which continued ten 
days, with some violence, but which did not recur. In November 
she was seized with sudden acute pain in the left iliac region, 
recurring from time to time, and of great severity. When Dr 
Drummond saw her, two months ago, he found a tumour in the left 
and lower part of the abdomen, pushing down into the pelvis, and 
there was aistinct ascitic effusion. She was very much emaciated 
and feeble, with oedema of the lower limbs, and altogether she 
looked very ill. The question at that time with Dr Drummond 
was, whether it was a case of malignant disease or of multilocular 
ovarian tumour complicated with ascites. 

She was placed on a full diet, with a liberal allowance of wine, 
and sent for change of air to the country. She returned to Dr 
Drummond in six weeks, with her general health greatly improved, 
bat with the abdominal swelling immensely increased, and ita 
ovarian nature now undoubted. 

I found a vigorous old lady, just entering on her sixty-eighth 
year, nearly blind, moreover, from double cataract. She was very 
sallow, ana extremely thin, with a dry, red, irritable tongue, but 
with a heart beating so quietly and firmly, that one's first imprea* 
sion waa, that with fair play such a constitution was good for many 
years to come. She complained mostly of flatulence, from which 
she had sufiered all her life, and attributed to it attacks of 
dyspnoea, which came on generally towards morning, and which 
were sometimes prolonged and severe. She still had diarrhoea 
from time to time. 

There was oedema of the lower extremities, and to a slight extent 
also of the abdominal wall. The tumour was veiy prominent, and 
extended up to the ribs on either side, the upper part of the abdomen 
being very much distended from flatulence. Immediately above 
the pubis was a projecting solid elastic mass, about the size of a 
child's head — the rest of the tumour was cvstic, but its upper 
mar^n was very ill defined, and it had a peculiar boggy feeling — 
leaving upon me the impression that some soft substance, such as 
the omentum or a mass of intestine, lay between the tumour and 
abdominal wall. In the pelvis it was entirely solid, an elastic 

{iece of it, coming very low down, filled up the recto-vaginal fossa, 
n front of the uterus, which was barely movable, it felt very hard 
and solid, and was continuous with the mass above the pubis. At 
first view this state of matters looked suspicious either ot malignant 
disease or of great pelvic adhesion. But after repeated examination 
I was satisfiea that the base of the tumour was free from attachment 
either to the rectum, uterus, or bladder. The tumour certainly had 
a peculiarly elastic feeling which I had not met with before, but it 
was just as likely to be adenoid as malignant, and this it turned 
out to be. 
About a week after I first saw her, she had a severe peritonitic 



1864.] CASES OF OTARIOTOMT BT DH KEITH, 289 

attack, occasioned hy being jolted in a cab. This was followed hj 
a large accumulation of ascitic fluid, which disappeared in a few 
days, almost as suddenly as it came, after some diarrhoea. Its pre- 
sence, however, completely cleared up the diagnosis of the pelvic 
portion of the tumour, but the upper part still retained the same 
ill*defined character that it had always presented; and at the 
umbilicus there was generally a small extent of clear sound over 
the tumour, as if at that point there was adhesion of the intestine. 
She remained under observation for a month, the tumour steadily 
increasing in all directions. She had occasional feverish attacki^ 
with abdominal tenderness, followed by ascitic accumulation, which 
came and went very rapidly. She was fast losing flesh and strength ; 
the dry red tongue still continued ; the disturbance from flatulence 
became more distressing, and the attacks of dyspnoea more frequent 
and severe. It was after seeing her in one of these attacks, which 
more resembled a paroxysm of angina, that I resolved to remove 
the tumour, for it was evident that her life was not now safe from 
one dav to another. Considering the great age of the patient, her 
great feebleness, her blindness, and the doubt as to the relations 
of the upper part of the tumour, this determination was arrived at 
with not a little difliculty. 

On the 21st April, 1 opened the abdomen very carefiilly, im- 
mediately below toe umbilicus. The wall was very thin, and a 
few touches of the knife exposed the surface of an ovarian cyst* 
This was emptied through a small trocar, and another upper cj^st 
then came into view* This was quite flaccid and half-empty, with 
part of the small intestine and mesentery adhering to it, and frilly 
explained the feeling communicated to the hand by external exam- 
ination. The omentum was very large, but was nowhere adherent. 
The intestine was then carefully separated, but its muscular coat 
was slightly exposed. Several small vessels in it and its mesentery 
were tied with silk — ^the ends cut short and left behind. The solid 
mass was then turned out of the pelvis without difficulty. The 
uterus came out with it, but there was plenty of room to secure the 
pedicle outside in the usual way. The whole weighed about four- 
teen pounds. 

For several days after the operation there was very great disten- 
tion of the abdomen, and there was a fear for a time that some low 
abdominal inflammation was going on, there being for some days 
considerable frilness of the recto-va^al fossa. On the fifth day 
there was some swelling of the parotia, which gave rise to great pain 
and constitutional disturbance, and went on to suppuration. After 
this, her recovery was unimpeded, and she returned to Ayrshire 
six weeks after the removal of the tumour. The tongue by that 
time had become pale and moist She had no more attacks of 
diarrhoea, and felt better than she had done for years. The last 
time I heard of her, she said she was ^^ as good as new.'' 



240 CASES OF OYARIOTOMT BY DR KEITH^ [SEFT. 

Case VIII. — Semi-solid Ovarian Tanumvy weighing 24 Iha, 
Ovariotomy. Death on the ninth day. 

J. M., aged 21^ a domestic servant, called on me in March last, 
on account of a semi-solid ovarian tumour^ extending nearly to the 
ensiform cartilage — her girth at the umbilicus being forty inches. 
She stated that nine months ago she came up from Golspie, a 
strong healthy woman; that for the last six months, since she 
became aware of the presence of the tumour, she had felt feeble, 
and unable to do almost any work ; that she rarely passed a da^ 
without sickness and pain ; that her nights were restless and wean- 
some ; and that for the last week she had been mostly inched. She 
was much depressed in spirits, and very anxious to have the tumour 
removed. 

A few days after this visit, she was obliged to take to bed, with 
severe abdominal pain, and almost incessant vomiting. This state 
of irritation continued, with short intervals of relief, for the next 
month. She was never able to be out of bed. and wnen she sat up 
she had a peculiar tendency to faintness, which was remarkable and 
unusual. In the middle of April she was removed to a suitable 
lodging, where for a short time ner general health improved. The 
vomiting ceased, she enjoyed her food, and slept well. She was 
then in a fair state for operation, and it would have been performed 
on the 21st had not the monthly period come on with ^eat violence, 
accompanied by such severe gastric irritation, vomiting, and pain, 
and such prostration of strength, that for some days she was in a 
most critical state, and it seemed as if she would never again get 
into a condition for operation. She rallied, however, and the tumour 
was removed on the 29th of April. Dr Benjamin Bell, Dr Traill of 
Dunfermline, Dr Carruthers of Cramond, and other friends were 
present. There was no parietal adhesion, but part of the omentum 
was firmly attached to the upper portion of tne tumour, — several 
vessels were tied with silk, and the ends of the ligatures cut 
off short and left. A piece of omentum, from which there was a 
good deal of oozing, was transfixed and tied, the threads being 
likewise cut short and returned. The pedicle was of good length, 
and was secured bv the clamp without any strain upon the uterus. 
Some ascitic fluid m the pelvis was then sponged out, and she was 
put to bed in a very good state. 

For the two days following the operation she remained in a very 
feeble and depressed condition, the pulse ranging from 120 to 150. 
There was, however, no pain, no vomiting, and no distention. On 
the third day the pulse had fallen to 100 ; and by the end of the 
first week her recovery was looked upon as undoubted. The abdo- 
men had remained quite flat ; the wound was perfectly united ; the 
stitches were all removed; the bowels had acted after the fourth day of 
themselves ; she had fair nights ; and took her food remarkably well, 
and was cheerful at the prospect of her early return to health ana 



1864.] CASES OF OYARIOTOVT BT DR KEITH. 241 

independence. But on seeing her on the morning of the ninth dfty, 
I was startled by her appearance, which reminded me of a case of 
typhus. She had had a restless night ; the pulse was up to 115 ; 
were was slight subsultus, and she was covered with a bright 
papular eruption. On calling in the evening, I found she had died 
rather suddenly about half an hour before. There was no post- 
mortem examination, but that blood-poisoning was the cause of 
death I have no doubt 

Case IX. — Unilocular Ovarian Tumour, Ovariotofny, Beeavery, 

M. C, 35 years of age, had been under the. observation of Pro- 
fessor Buchanan of Olasgow since the tumour was first detected 
about three years ago. Latterly its growth has been very rapid ; 
and as soon as she began to lose flesh, and her general health to be 
threatened by the disease, he recommended tne removal of the 
tumour. 

This I did at Glasgow, on the 6th of May, at Professor 
Buchanan's request. Dr Drummond of Glasgow, Dr George 
Buchanan, and other friends were present. The cyst was easily 
removed through an incision three inches in length, and a long 
slender pedicle secured by the clamp ; the whole proceeding being 
of the simplest kind possible. 

I saw her a week afterwards, and removed the clamp, and she 
made an excellent recovery. 

Case X. — Semi-solid Ovarian Tumour ^ toetghing 35 lbs. 
Ovariotomy. Recovery. 

In April last an unmarried lady, forty-seven years of age, the 
daughter of a medical man, was recommended to me by Dr Cumming, 
and Dr Grigor of Nairn, as a fit subject for ovariotomy. The 
tumotir had been detected about six months before, and had been 
of very rapid growth. All along there had been a great deal of 
pain ; while for the last three months the general uneasiness had 
Deen so extreme, that she had been unable to sit or lie in any 
position, by day or by night, for any length of time. Before the 
commencement of her illness she had been very plethoric, but she 
was now losing flesh very rapidly. 

Three weeks before I saw ner, she had been tapped by Dr Grigor 
below the umbilicus, and about fourteen pints of fluid removed. 
She had little relief, liowever, from this, for the upper part of the 
tumour did not subside, and it had again nearly regained its former 
dimensions. The largest cyst that could now be detected was 
above the umbilicus, and the cyst formerly emptied did not appear 
to have refilled. The greatest ffirth was forty-three inches. 

On meeting, on the 10th of May, with Dr Arthur Mitchell and 
Dr Cumming, for the purpose of removing the tumour, her general 
condition was so unfavourable, that it was agreed to postpone the 
operation, and simply to tap the upper cyst, in hopes of giving 



242 OASES OF OYABIOTOHT BY DR KEITH. [SEPT. 

some relief. This cjst was found to contain about fourteen pounds 
of fluid^ and she felt so much more comfortable after the tapping^ 
and had such good nights, that we felt warranted on going on witn 
the operation, on the 20th of May, ten days after the tapping. 
The tumour was semi-solid, and there were extensive but easily 
broken down adhesions in all directions. These were separated, as 
hi as the hand could reach. The tumour was then cut into and 
broken up. When its size was much reduced, the hand was again 
passed in, and some adhesion to the small intestine and extensive 
adhesion to the stomach separated ; and I was then able to with- 
draw the whole without extending the incision above the umbilicus. 
The pedicle was of fair length, and was secured as usual hy the 
clamp, and the wound closed by silver sutures. 

It would occupy too much space to go into the details of the 
tedious convalescence which followed, — the longest by far I have 
yet met with after ovariotomy. Violent peritonitis, nearly proving 
fatal, set in on the third day. This was followed towards the end 
of the first week, by effusion into the left pleura ; and to this again 
succeeded a second attack of general pentonitLs of great severity. 
The wound, which seemed at first to have united, towards the end of 
the second week, took on unhealthy action, and opened up through its 
whole extent. Great sloughing of the cellular tissue of the abdo- 
minal wall followed, and the tracks of the wire sutures became con- 
verted into so many different sinuses, which went on discharging 
for weeks, the wound itself slowly healing by granulation. She 
had also bed sores, and lay for many weeks in a state of great 
feebleness on a water bed ; and it was not till two months after the 
operation that she was able to make the lon^ railway journey to 
[Nairn. She is now quite well, and becommg a strong woman 
again. 

Case XI. — Multilocular Ovarian Tumour weighing upwards of 
65 lbs. Omriotomy, Death from Exhaustion. 

•Mrs W., «t. 29, but looking twenty years older, came to me 
with a verv large ovarian tumour. She had been seen, for the first 
time, the day before, by Dr Lum^air of Largo, who, though recog- 
nising the advanced state at which the disease had amved, still 
thought the case might be one for ovariotomy, as the patient had, 
till the detection of the disease eighteen months before, been 
remarkably healthy, and she was of a vigorous and healthy 
family. 

She had already been tapped three times, and had taken a great 
deal of medicine of various kinds. Till two months before 1 saw 
her she had not suffered much firom her complaint, and had not lost 
much flesh, and was generally able to look after her household affairs. 
She then imderwent a prolonged mercurial course, which she said 
completelv took the flesh off her bones. Since then she has been 
very feeble. 



1864.] CASES OF OYASIOTOMT BY DR KEITH. 248 

She was exceedingljr emaciated, and presented in a well-marked 
degree the weary, miserable, faaggara appearance of advanced 
ovarian disease. The tnmonr was very large^ measuring upwards 
of forty-nine inches a little above the umbilicns. Between the 
anterior spine of the right ilium and the umbilicus the measure- 
ment was seventeen inches ; between the spine of the left ilium and 
the umbilicus she measured twenty-one inches; and the space 
between the ensiform cartilage and pubis was thirty inches. The 
abdominal wall was, over a large extent, thickened, brawny, and 
oedematous. The tumour was mostly composed of one very large 
cyst, but there was a considerable amount ot solid matter on the left 
side low down* The uterus was central, normal, and very movable. 

She was a woman of great resolution, and though she was well 
aware that her case was an unfavourable one, she wished to take 
her chance of the operation, in the hopes of being restored to her 
husband and children. 

She was tapped the day after I saw her, and upwards of sixtv 
pints of very thick ovarian fluid were removed. She was mucn 
relieved. Sue was put upon a ftiU diet, and slept better than she 
had done for months. The usual monthly period, after being 
delayed for a week, continued for ten days. Nearly tnree precious 
weeks were thus lost, the cyst was filling with great rapidity, and 
her strength had greatly diminished. 

The tumour was removed on the 23d of Mav. Professor Syme, 
Professor Lister, Dr Lumgair of Largo, and other friends were 

? resent. The girth had already increased to forty-three inches, 
^he cyst was wounded in opening the peritoneum, and the contents 
were allowed to escape. There were extensive parietal and omental 
adhesions, and more bleeding than usual from the torn vessels, as 
I have always observed is the case when the abdominal wall is 
much thickened. Several vessels in the omentum and wall were 
tied with fine silk, the ends cut off and returned. A long thin 
pedicle was secured by the clamp as usuaL Owing to a free oozing 
from the torn adhesions, the operation was prolonged, and there was 
much more sponging and handling of the parts than usual. 

She had a quiet night, and required but one small opiate enema. 
The urine was copious, and perspiration moderate ; and she took 
from time to time some beef-tea and other simple nourishment, with 
an occasional small quantity of stimulant. She complained all 
along of feeling very tired, and though she promised well next 
forenoon, her pulse, though not frequent, was very feeble ; and she 
died in forty-six hours, as one dies from the ishock of a great injury. 

Case XII. — Ovarian Tumour nearly Unilocular. Ovariotomy. 

Recovery. 

An unmarried lady, now twenty-seven years of age, was seen in 
November 1861, by Mr Wells, who diagnosed an ovarian cyst, 
unattached anteriorly, with a secondary cyst or cysts in the wall 

VOL. X.— NO. III. 2 1 



244 CASES OF OVABIOTOHT BT DB KEITH. [SEPT. 

a little below the umbilicns. Her health was then good, and he 
recommended her to wait. Some time after this, on her return 
home, she was for many weeks confined to bed from supposed 
cjst inflammation^ and her general health was for long veiy mdif- 
ferent. I first saw her towards the end of last year. She was 
then in good healthy but thin, and measured forty-one inches at 
the umbilicus. The cyst was still apparently unattached, and the 
secondary cyst felt by Mr Wells three years before had not in- 
creased, though its position was now more upwards — ^sometimes 
to the left of the umbilicus, and sometimes near the edges of the 
false ribs. Delay was still recommended. 

I saw her again with Dr Dunsmure in May last. The tumour 
was steadily increasing. She was losing flesh and was getting 
anxious to be relieved of her burden, and we agreed to remove it, 
believing that it was safer to do so than to tap so large a cyst 

This was done on the 30th of May. Dr Dunsmure and Dr 
Gordon of Old Aberdeen were present. The large cyst,* contain- 
ing forty pints of fluid, was emptied, and together with a sin&rle 
secondary cyst, was easily withorawn through an opening in ttie 
peritoneum about two inches in length. As 1 was aoout to applj 
the clamp, a small cyst in the broad ligament was observed. Tnis 
led to a more careful examination of the attachment of the cyst, and 
no fewer than seven small cysts, about the size of beans, were dis- 
covered, some of them near the uterus. The ovary itself, diseased 
and slightly enlarged, was close to the uterus, and quite sessile. A 
double ligature was placed under it, but it could not be got into the 
clamp, which was applied almost close to the uterus. From the 
thickness of parts embraced in the clamp, a single stitch sufficed to 
close the wound. Before tightening the stitch, the strangulated 
ovary was brought out alongside the clamp and secured to it 
Owing to the great laxit]^ of the abdominal wall, there was not 
much strain upon the pelvic tissues, though the uterus was brought 
up close to the wound. 

On the second day the monthly period came on with great 
violence, and there was for two days a copious discharge of men- 
strual-like fluid from the incision. The clamp was removed at 
the end of a week, but the ligatures round the strangulated ovary 
did not separate for five weeks after the operation. Her recovery 
was uninterrupted* 

Case XIII. — Semisolid Ovarian Tumour umghing Thirtysix 
Pounds. Ovariotomy. Recovery. 

Miss W., aged thirty, recommended to me by Dr Haldane of Avr. 
on account of a large semi-solid ovarian tumour of about six months 
growth. When I saw her in the beginning of June, her greatest 
^irth was thirty-eight inches ; there was one cyst of considerable 
size above the umbilicus, the rest of the tumour was semi-solid. 
She was in pretty good health, but wasgetting very thin about the 



1864.] CASES OF OVABIOTOMT BT DB KEITH. 245 

arms and shonlden. She cotdd walk bat a very short distance, and 
her nights were bad. 

By the Ist of July her girth had increased to forty-two inches 
and a half, and there was some oedema of the limbs. To relieve 
this and to give her some good nights before the operation, I 
emptied the upper cyst, which contained about eight pounds of 
fluid. I removed the tnmpur on the 8th of July. Dr M^Lan- 
naghan of Daliymple was present. Some ovarian fluid^ mixed 
with large flakes of lymph, escaped on opening the pentoneum. 
I then cut into the tumour, passed in my hand and broke it up. and 
with some difficulty was able to withoraw the whole througn an 
incision not exten£ng above the umbilicus. There was a great 
deal of sponging necessary. The pedicle was of fair length, and 
was secured by a clamp, and the wound was closed by six deep 
and three superficial silk sutures in the usual way. 

She got very sick with the chloroform, and vomited bile for the 
next twenty-four hours, but her pulse never rose above 70, and her 
recovery was unusually rapid. The sutures were removed on the 
fourth oay, except one close to the clamp which had escaped notice, 
which was removed on the eighth day. There was not a sinrie 
drop of matter along the track of any. By the middle of the 
third week she was going about quite well, and she went to her 
home, near Ayr, four weeks after the operation. 

Case XTV. — Large Cyst containing Fifty-five Paunch ofMuicL 

y. itecovery. 



Miss B., a^ed thirty-five, a patient of Dr Halliday Douglas, had 
been aware of the existence of an ovarian tumour for about twelve 
years. I saw her first six years ago. At that time it filled up the 
whole abdomen; was unilocular, and unattached. It steadily 
increased, and now she measures forty-four inches at the umbilicus, 
twenty-nine between the ensiform cartilage and pubis, and twenty- 
eiG;ht inches between the one anterior spine of the ilium and the 
other. There is great elevation of the nbs. and great displacement 
of the heart, for its impulse is felt below tne third rib two inches 
firom the mesial line. She has latterly become very nervous and 
thin, and has bad nights. 

On the 25th of July, I opened the peritoneum to the extent of 
two inches and a half^ tapped, and drew out the cyst, which con- 
tained between five and six gallons of fluid. The cyst was almost 
sessile, and the clamp was placed roxmd its base, the uterus being 
brougnt up nearly to the abdominal wall. One deep silk suture 
was sufficient to close the wound. 

For several days after the operation she suffered from severe 
cardiac pain, apparently of a neuralgic nature, with a frequent ten- 
den<rfr to syncope. There were no abdominal symptoms whatever, 
and her recovery was rapid and uninterrupted. 

The following table contains an account of all the operations for 



246 



CASES OF OVARIOTOMY BY DR KEITH. 



[sept. 



oyarian tumour^ which I have up to this time performed. Of twenty 
cases in all, six patients died after the operation, and fourteen 
recovered perfectly, and are now in good health. 

Table of Twenty Cases of Ovariotomy. 



No. 


Dftt& 


< 


Conditlt^a. 




1862. 






1 


Sept. 


49 


Married, 


S 


Jan. 


66 


Married, 


8 


Feb. 


24 


Married, 


4 


March. 


27 


Married, 


6 


May. 


22 


Unmarried, 


6 


July. 


62 


Married, 


7 


Aug. 


28 


Married, 


8 


Sept 


23 


Unmarried, 


9 


Oct. 
1864 


16 


Unmarried, 


10 


Jan. 


66 


Married, 


11 


Feb. 


40 


Unmarried, 


12 


March. 


60 


Married, 


18 


April. 


68 


Married, 


14 


May. 


23 


Unmarried, 


15 


May. 


86 


Unmarried, 


16 


May. 


29 


Married, 


17 


May. 


47 


Unmarried, 


18 


May. 


27 


Unmarried, 


19 


July. 


80 


Unmarried, 


20 


July. 


88 


Unmarried, 



History, etc. 



Result 



Multilocnlar; 251b. ; sarronnded by ascitio fluid; 

Multilocnlar; 46 Ih ; 

Multilocnlar; 681b.; tapped once; 

Mnltilocular ; upw. of 120 lb. ; tapped 4 times ; 

Multilocnlar; 88 lb.; since married ; 

Fibro-sarcomatous, and cystic ; 

Mnltilocular; nearly 80 lb.; tapped 7 times; 

Multilocnlar; 401b.; tapped twice; 

Semi-solid; rerylarige; tapped oooe;. 

Seml-solld; 231b.; tapped twice; 

Mnltilocular; 37 lb. ; tapped once; 

Large single cyst; 

Cystic and adenoid; 

Semi-solid: 24 lb.; 

Large single cyst; 

Mnltilocular ; 66 lb. ; tapped 4 times; 

Semi-solid; 861b.; tapp«d twice; 

Mnltilocular; 86 lb.; 

Semi-solid; 861b.; 

Very large single cyst, containing 66 lb. of fluid ; 



Remains welL 

Remains welL 
Died 28 hours after. 
Remains welL 
Remains well. 
Died 6th day. 
Died 88 hours after. 
Remains well. 
Remains well. 

Remains well. 
Died 6th day. 
Remains well. 
Remains welL 
Died 0th day. 
Remains welL 
Died 46 hours after. 
Remains well. 
Remains well. 
Remains well. 
Remains well. 



I^art Secontr. 



REVIEWS. 

A Treatise an Hygiene with Special Reference to the Military Service. 
By William A. Hammond, M.D., Surgeon-General U. S. 
Army. Philadelphia : Lippincott. 8vo, pp. 604. 

This is a work written by a military surgeon of exalted rank, 
during a war of unparalleled dimensions, and with special reference 
to the military service. But it does not treat exclusively of military 
hygiene. It contains much that applies equally to the civilian and 
the soldier. It is, in truth, an epitome of the copious literature of 
sanitary science, placing before the reader, in a volume of moderate 
size, all that is practically worth knowing in the science and art of 
prevention. 

The book has been written to supply an acknowledged want; 
the author believing that " a great necessity existed for a treatise 
upon some of the pnncipal subjects of hygiene." Whilst professing 
a lively faith in the actions of magistral remedies, Dr Hammond 
maintains that the influence of hygienic measures has been too 



18e4.] DB HAMMOND'S TBEATI8E ON HTOIENE. 247 

much overlooked ; and that dmes, the traditional actions of which 
have been positively disproved by physiological and chemical 
researches, as well as by the soundest pathological deductions, are 
too fireqnentlj administered through tne constant pursuit of that 
routine practice which at once hinders the development of medical 
science, and cramps the powers of those who labour for its advance- 
ment. He thereiore endeavours to take a broad view of his subject^ 
to the intent that his book may be generally useful. But Dr 
Hammond had a stronger motive than that of supplying the pro- 
fession with general knowledge, when he undertook, m addition to 
his already onerous labours, tne preparation of the present volume. 
From the lon^-continued and profound sleep of peace, his country 
awoke to the horrors of a gigantic civil war. An army had to be 
made, which, when marched mto the field, consisted of officers and 
men alike unversed in their duties. To protect the Federal army 
from the effects of the numerous external causes of disease which 
cling so tenaciously to the camp, was the duty of the medical 
officers. But they were inexperienced men, who had not so much 
as witnessed a Cobham or an Aldershot. Dr Hammond made to 
himself the following proposition, which is demonstrated in the 
book before us : — " In me military service," he says, " more than 
any other, a knowledge of tUb means of preventing disease, and of 
facilitating recovery by methods other than the mere administration 
of drugs, is necessary. Armies are often so situated that their 
salvation depends upon the knowledge which the medical officers 
mav possess, and it never happens that some important application 
of hygienic principles cannot be made to them by those who are 
charged with their medical superintendence." 

Dr Hammond's book is not a mere compilation ; it consists, in 
part, of the results of his own personal investigations, which, having 
accumulated through manv years of active and responsible practice — 
formerly as Professor of Anatomy and Lecturer on Clinical Surgery, 
and recently as a Surgeon-General in the army — are entitled to 
respectful consideration. 

The book is divided into forty-one chapters, some of which are 
very short, and their subjects insufficientlv treated — shortcomings 
not unlikely to occur in a work written at high pressure, but which 
mav be atoned for in a fdture edition. 

We shall not undertake a criticism of Dr Hammond's work ; it 
is written for the information of those who run, not for those who 
have leisure to examine the various paths by which the author 
reached his conclusions. Nor can we do more than briefly advert 
to one or two topics which the author conceives to be of paramount 
importance. 

The opening section treats of the qualifications and disqualifica- 
tions of recruits. The Federal armv is now numerically larger than 
that of any other country in the world ; but that does not of necessity 
imply that its aggregate physical strength surpasses thatof aEuropean 



248 DR HAMHOKD^S TRISATISE ON HTGIENE. [$EFT. 

army of half its size. Tailors, shoemakers, and bricklayers cannot be 
made soldiers in a day ; they may don the uniform and shoolder the 
rifle, but th^ are soldiers only in name until they haye passed through 
the ordeal of a regular and severe course of training. W hen the author 
speaks of the ill condition of the earlier drafts of men, he oyerlooks 
the fact that the Federal Government had no choice when it allowed 
" incapables " to enter the army at the outset of the campaign* 
Beady-made soldiers were not forthcoming in sufficient numbers, 
and when the first shot was fired, hundreds of thousands of hearts 
quivered, for they knew not the meaning of war. If any of the 
first-drawn men remain, they are veterans now, and- have learned 
the lesson of war by a protracted exposure to its horrors and its 
hardships, and by the witness of human butchery, such as civilized 
nations nad deemed impossible. The experience afforded by the 
present American war shows truly the importance of a carefol in- 
spection of recruits ; but it teaches a wiser lesson than that — it tells 
us the necessity of preserving our veteran troops, by all the 
machinery of efficient sanitary reflations, if we would avoid the 
dilemma of sending cripples to the front. The early condition of 
the Federal army — ^judging from the author's remarks — ^must have 
been deplorable in the extreme. 

^^ The present rebellion has opened our eyes to the evils flowing 
from the mdiscriminate enrolment of men imnt, by reason of physicsu 
infirmities, to undergo the hardships incident to a soldier's life. 
Thousands of incapacitated men were in the early stages of the war 
allowed to enter the army, to be discharged after a few weeks' 
service, most of which had been passed in the hospital. Many did 
not march five miles before breaking down, and not a few never 
shouldered a musket during the whole term of their service. In a 
hospital under my charge, containing six hundred beds, I discovered 
at one time, on inspection, fifty-two cases of inguinal hernia in men 
who had undergone but an insignificant amount of exposure to 
hardship. Cases of chronic ulcers, varicose veins, epilepsy, and 
other conditions unfitting men for a military life, came frequently 
under my notice. The recruits were either not inspected at all by 
a medical officer, or else the examination was so loosely conducted 
as to amount to a farce. I know of several regiments in which the 
medical inspection was performed by the surgeon walking down the 
line and looking at the men as they stood in the ranks. Not long 
since a case was reported to me by an intelligent surgeon, in which 
the colonel of the regiment to be inspected refused to allow the men 
to be stripped in order to undergo examination. Matters, however, 
are better arranged now than at the commencement of the rebellion ; 
but there is every reason to believe that sufficient care is yet by no 
means taken to prevent the entrance of men into the service who 
are rather subiects for the hospital than soldiers fit for the field." 

The first chapter is confined to the circumstances which in a 
general way affect the aptitude of a man for military service, in- 



i8Gi.] DR Hammond's tbeatise om hygiene. 249 

dading age, statnre, etc. The second chapter treats of the niecial 
qnalifieationB and disqualifications, and the sabject is oonsiderea from 
an anatomical point of view, the development and diseases of the 
different regions of the body being discussed in their order. Thia 
completes the first section of the work. The second section is 
divided into ten chapters, and discusses the agents inherent in 
the organism which affect the hygienic condition of man. This 
section is of a more general character, including the subjects of race, 
temperaments, idiosyncrasies, age, sex, hereditary tendencies, habits, 
and constitutions. The third section consists of twenty-nine cnapters^ 
in which the subjects of climate, in its several aspects, the sanitary 
reg^ulations of hospitals, barracks, camps, diet, dress, clothing, and 
others are considered. 

The chapters relating to the construction, ventilation, lighting, 
heating, etc., of hospitals, barracks, and camps, are full ot valuable 
information. Several drawings are made use of to illustrate this 
part of the work, and examples of the excellencies and evils of such 
Dtdldings are drawn from those existing in various parts of the 
world. One of the oldest forms of hospital, that in which three or 
four sides of a square are built upon, is particularly condemned. 
Ourfs Ho»piudj Necker^ BicStre^ acJpetrih'ey Saint LauiSy and the 
Maiaon Muntcipale de SanU of Paris, the Oapitale Maggiori di 
MilanOj and the Military Hospital in Algiers j are all built upon the 
general principle of the closea court or hollow square, and are alike 
disapproved. The principles which Dr Hammond enlarges upon in 
the construction and administration of a hospital are : — 

1. That it is capable of being well ventilated. 

2. That it is sufficiently capacious for the number of inmates it is 
to contain. 

3. That it admits of good drainage. 

4. That it is provided with a sufficient number of windows. 

5. That the kitchen, laundry, and other offices of administration 
axe well arranged and of ample size. 

6. That efficient water-closet, ablution, and bathing accommoda- 
tions are provided. 

7. That it is amply supplied with water, and gas, or other means 
of illumination. 

8. That the fomiture, of all kinds, is of suitable quality. 

9. That the officers and attendants have their proper respective 
duties assigned to them, and that they are in number sufficient for 
the wants of the sick. 

10. That proper rules are established for the government of the 
hospital, for the diet of the inmates, and for preserving order, and 
an efficient state of police. 

The concluding nine chapters on diet and clothing also abound 
With useful information. They contain much of the author's per- 
gonal knowledge acquired by actual observation and scientific inves- 
tigation, as well as the results of laborious research. This subject 



260 DR Hammond's tbeatise on hygiene. [sept. 

id not new to Dr Hammond ; he has previously written on it in his 
Physiological Memoirs^ and in his prize essay On ike NtUridve 
Value and Physiological Effects ofAUmmen^ Starchy and Qvmy when 
singly and exclusively used as Food, published in 1856. The relative 
value of the different articles of diet is estimated, and the diet tables 
of the U. S. Army are given in full. Dr Hammond's book is 
worthy of the careful attention of military medical officers, and 
cannot fail to be most useful to his brethren at present engaged in 
the American struggle. 



Lectures: Chiefly Climcal. By Thomas King Chambers, M.D., 
Physician to St Mary's and the Lock Hospital. London : 
Churchills: 1864. 

The volume before us is a new and much enlarged edition of a 
work to which we some little time ago directed the attention of our 
readers.^ At that time it bore the title " The Renewal of Life ; " 
but as that designation was pretty generally objected to, Dr 
Chambers has changed it to that which it now bears. In our 
former notice we stated that^ in Dr Chambers' opinion, disease con- 
sisted in all cases in a deficiency of vital action, and that it was the 
object of rational medicine to " renew life ; " in other words, that 
the treatment of the scientific physician should be mainly restora- 
tive. With the importance of these principles Dr Chambers is 
" more than ever impressed," and the present volume contains faller 
illustrations of these than the preceding. For our own part, we 
have to repeat what we formerly stated, that while in general we 
agree with the plans of treatment of disease recommended by Dr 
Chambers, we consider his system of pathology as too exclusive. 

The first new subject treated of in this volume is " The forma- 
tion of mucus and pus ; " the three chapters in which it is considered 
having formed the Lumleian Lectures delivered before the College 
of Physicians in 1863. A ereat part of them is to a considerable 
degree out of place in a work on Clinical Medicine, but we allude 
to them for the same reason on account of which, no doubt, Dr 
Chambers introduced them, because they constitute good examples 
of his peculiar pathology. Dr Chambers maintains that, in the 
healthy state, mucous membranes do not secrete mucus, but that 
they are merely moistened by a watery exhalation which contains 
no morphological elements except a little effete epithelium. When 
disease sets in, and the vitality of the part is mminished, mucous 
globules make their appearance^ and this mucus is to be regarded 
as a parasite, its globules retainmg no higher function of life than 
a reproductive force. In a still higher degree of deficient vitality 
the fluid becomes purulent, the pus globules, according to ui 
^ See this Joamal for November 1863, p. 454. 



1864.] DR chambers' CLINICAL LECTURES. 251 

Chambers, being ^' parasites inside the epithelial cells, capable of 
increase by propagation within the tissue, just as on the sur&ce the 
mucous globules were shown as parasites capable of increase by 
propagation without the tissue. And they grow quite independent 
of tne true nucleus of the cell, and are not derived from it." 

Into the histological arguments by which Dr Chambers attempts 
to establish these positions we hare neither space nor inclination to 
follow him, particularly as we do not exactly understand his state- 
ments regarding the mode of development of mucous and pus 
corpuscles, when he endeavours to reconcile and work into a single 
system the observations and conclusions of men who differ widely 
from one another, such as Henle, Virchow, Beale, Fdrster, Buhl, 
and others. The following passage contains statements with which 
very few modem histologists will agree : — 

** In solid stmctureB this effusion is followed by an endosmotic current of 
the watery part back again into the circulation, leaving behind it the more 
solid and coagulable constituents. On free surfaces, covered only by soft open 
epithelium, the water and salts therein dissolved escape, forming the fluid of 
tne mucus. The elements of new tissue, being there very copious to supply 
the constant demand for growth, ooze out copiously with the serum, and 
constitute the mucous globules. They are wasted elements of new growth, 
not themselves a new creation, or evidences of superadded life. 

*^ How do these matters get tlirough the coats of the capillaries ? There 
cannot be holes for their escape, or else the blood-discs, which are the smaller 
of the two, would escape also. Doubtless this is one of the great riddles of phy- 
siology. But the art of drawing is in a certain d^ee responsible for some 
of the difficulty which it presents to our minds. When we have no means 
of correcting by our other senses impressions made on the eye, we are too apt 
to consider everything with an outline as equally solid. The necessarily hard 
outlines of the engraver express to us forms which may, for all the paper 
shows, be spheres of cast iron, whereas in truth they are as delicate as aerial 
clouds. Why may the^ not pass through tissues, mutually dissolving and 
dissolved by the matenals of those tissues? Just as we see a stratum of 
fleecy cloud among mountains, or in Turner's pictures, disappear when it 
comes to a stratum of warm air, and reappear in the same form when it 
emerges on the other side. To get just ideas of nature, we must look upon 
solidity as a comparative, not as an absolute, quality.** 

For OTir own part we cannot look upon increased, even if some- 
what altered^ secretion, as bj any means invariably a sign of 
diminished vitality. If a gram of sand be lodged in the conjunc- 
tiva, the effect is a greatly increased flow of tears, by which, very 
probably, the offending body will be washed away. There is 
nothing morbid up to this point ; it is an example of how the tissues 
can take on increased activity ; no doubt, if goinff too far or con- 
tinuing too long, it would verge into disease, but if restrained 
within due limits it is really physiolo^cal. Or, it may be said to 
constitute an example of that nutritive irritaoility, by virtue of 
which tissues can assume to themselves a larger amount of nutritive 
irritability, although if it exceed certain limits a diseased condition 
is the result. 

With the therapeutical statements with which the third of these 

VOL. X.— NO. III. 2 K 



252 BR CHAMBERS*^ CLINICAL LECTURES. [SEPT. 

chapters concludes, we genendly agree. A certain degree of cold, 
and a firee supply of oxjgen, in the form of atmospheric air, are to 
healthy surfaces invigorating and Ibeneficial ; if, however, their 
vitality be lowered, the agents, instead of being salubrious, become 
deleterious. Hence, no doubt, it is that a layer of healthy pus is 
the best covering for a raw surface; and for this reason Dr 
Chambers would not encourage too free expectoration in the early 
stages of pulmonaiy afiections, because the mucus thrown out forms 
the best covering for the inflamed membrane. Afiter having 
spoken of the effects of warmth and moisture, the chapter concludes 
with the following passage, the statements in which we believe to 
be in the main true, though opposed to the views at present fiuhion* 
able with regard to the all-importance of ventilation : — 

"The recognised benefit of moist warmth may, I think, suggest to as 
something more. When an animal submits to the periodical latency of the 
higher functions which takes place during sleep, it inatinctiTely seeks the 
warmest birth it can find; it is instinctively careless about the supply of 
oxygen so that it can get heat. Beasts hide themsdres in unventilatea dens 
and burrows ; man surrounds himself with blankets and curtains in a close 
bedroom, and not all the questionable aimiments of busy philanthropists can 

Sersuade him to open his window at nignt. I suppose that instinct is here* 
itary experience transmitted by generation from sire to son, and continuously 
increased through countless ages. It is not surprising, therefore, that its 
silent voice should beat out of the fidd the voice of argument, however loqua- 
cious. But I doubt if we physicians listen for it carefully enough. In that 
state of deficient vitality wnich constitutes disease, we are ndly apt to leave 
to accident the duty of cherishing the weak life by warmth, in every hos- 
pital I enter, the wards are a great deal too cold. Because their foremthers 
tried to keep the sick warm by unwise methods, the public in the present 
day zealously oppose the better means of healthy warmth which new inven- 
tions provide. Can we be surprised at rheumatic patients fiillin^ into peri- 
carditis, at fever patients havmg pneumonia, when house- visiters, vigorous and 
well fed, walk in from the park, and finding the wards smell of mutton- 
broth and poultices, order the windows open without compunction ? Such 
things are ; but they might be prevented if physicians would first convince 
themselves, and then the public, that an atmosphere and a temperature whick 
is sCTeeable and wholesome to the healthy, need not be either agreeable or 
wholesome to the sick." 

The only other chapter we can notice is headed " Atrophy of 
Muscles." Before, however, speaking of the special subject of it, 
we have to make a remark on Dr Chambers' views on hypertrophy, 
as therein expressed. Dr Chambers says, — 

" You may be tempted to inijuire, if over-use of voluntary muscle causes 
atrophy, and under-use also, whilst moderate use leaves our frames well-pro- 
portioned, what sort of use it is which induces hypertrophy. I confess that 
in spite of the dedei rtpetiia statements of physiologists, who have been copy- 
ing one another from the time of Glalen, I ao not know that any kind of use 
at all does so, in the sense of making the substance of the muscle larger 
when measured in a state of rest. Doubtless an actively employed iHceps or 
gastrocnemius will more readily be acted upon by the voluntary nerves, will 
contract more strongly, and be harder and more prominent when contracted ; 
but I cannot find that it grows at all bigger. I do not absolutely deny the 



1864.] DB CHAMBERS^ GUNICAL L£GTURK& 258 

existence of the physiological hypertrophy of miucle ; I only My tbiU al all 
events it is very rare, for I cannot find any instance of it. 

" The most notable example of muscular hypertrophy ought to l»e an active, 
well-made, one-legged, or lame man ; seeing he oses one leg instead of two, 
it ought surely to be enlaiged. Yet in meaauring in several instances the 
remaining leg in a state of rest, I cannot find tliat the proportion which it 
bears to the arm is at all different from the proportion in ordinary persons of 
the same build. And I cannot find that as a rule blacksmtth*s arms are out 
of proportion to their legs. Both are muscnUff ; for none but a muscular man 
can work at such a tn^e, and when excited, the brachial muscles contract 
firmer than those of the lower extremity, and are more marked ; but they 
are not disproportionately large when relaxed." 

This statement agrees with the rest of Dr Chambers' pathology, 
the idea appearing to be, that as hypertrophy of muscle implies 
increased action or vitality, it does not exist, or is extremely rare. 
With this opinion we ao not agree. We have undoubted and 
frequent examples of physiological hypertroph}r of muscle in the 
case of the heart Take a case of moderate aortic constriction ; in 
consequence of the diminished size of the orifice the ventricle can 
no longer supply the system with a full supply of blood ; but a 
want is experienced by the tissues, and in order to supply it the 
ventricle is called upon for increased exertion ; this increased exer* 
tion calls for additional nutritive energy, and in no long time the 
ventricle becomes hypertrophied. If the increased bulk of muscu- 
lar fibre retain its healthy structure, and if no dilatation of the 
cavity take place, the hypertrophy may be regarded as physiologi- 
cal, because compensating to a certain degree lor the obstruction to 
the circulation occasioneaby the contracted orifice. Neither do we 
attach much importance to Dr Chambers' illustration of the one- 
legged man ; for though he uses one leg instead of two, the one 
leg does not do the work of two ; as progression is effected not by 
the single leg, but by it aided by the muscles of the back and 
arms applied through the medium of crutches or other means of 
profession. 

Dt Chambers' observations on the atrophy of muscles we con- 
sider exceedingly good. He describes several cases of muscular 
atrophy in which the disease appeared due to over-exertion of the 
muscles, and then makes the following remarks : — 

** You may easily recognise in all these cases the same evil in action under 
corresponding circumstances — atrophy produced by local overwork of volun- 
tary muscle. And if yon think, and examine closely the relations of the 
muscle to the rest of the organism, yon will see that this overworked tissue is 
in a position not very, different from the underworked tissue, whose degenera- 
tion IS so generally made the subject of remark by physiologists. The defect 
is in both mstances a want of renewal. In underwork no demand is made for 
renewal, and in overwork the demand is made, but is not efficiently supplied. 
In the one the nerve-force, which should guide and govern the metamorphosis, 
is let lie asleep, and in the other has been so used up by unwonted toil, that it 
is exhausted, and for a time does not exist. So that the last effect on the mus- 
cular fibre is the same. No new store of muscular subetance is laid in, and the 
old degenerates into inelastic fibre, and finally into a pale fatty tissue of still 
lower vitality.'* 



264 . DR CHAMBEBS' CLINICAL LECTURES. [SEPT. 

The same principle is applied, we think, correctly to the explana- 
tion of the palsy occasioned by poisoning with lead : — 

" I am disposed to explain a great part of the pathology of painter^s dropped 
hand on the same principle which I stated to yon on a former occasion apropos 
of simple muscular atrophy. The white lead is slowly absorbed by its gradual 
and sparing solution in the fluids of the bod^r, which are rendered capable of 
dissolving it by their saturation with carbonic acid. In the blood it destroys 
the red globules, and carried to the muscles removes their red colour also, 
and renders them incapable of contracting except under extraordinary nervous 
influence. This paralyzing effect is most commonly shown on the involuntary 
fibres of the intestines, producing the well-known painters' colic. There are 
two reasons why it should be exhibited soonest on these intestinal fibres; 
first, they are the nearest to the usual portal by which the poison enters, 
the path of the food ; secondly, they are weak muscles, and yet have constant, 
almost unintermitting work to do, so that they can have but little repose 
during which recovery from exhaustion might be possible. Hence colic and 
constipation from arrested vitality in the mtestines is the commonest result 
of lead poisoning. 

To the muscles of voluntary motion in the trunk and limbs the same prin- 
ciples apply, and most especially the latter. Those muscles become most 
paralytic which are most exhausted by the peculiar employment of the indi- 
vidual. 1 had a patient a few years ago whose work lay in a sheet-lead ware- 
house, and consisted of moving very heavy masses of that weighty metal. He 
became gradually paralytic in the right forearm, and weak in the loins, parts 
extraordmarily exhausted by his labour." ' 

In conclusion, we have only to say, that while on various points 
we do not agree with Dr Chambers, we consider that his book, 
especially in its present form, contains much valuable matter, and that 
it is calculated to prove a trustworthy guide to the practitioner. 



Treatment of Diseases of the Skin. By Dr William Frazer, Lec- 
turer on Materia Medica. Dublin : Fannin and Co. : 1864. 

This little work does not treat of the whole subject of skin diseases, 
but, as its name implies, is principally devoted to their treatment. 
It is divided into cnapters, each treating of a group of remedies, 
under which their therapeutic actions in the different skin diseases 
is considered. Thus we have chapters on Mercurials, Arsenic, 
Chalybeates, Desiccants, Baths, and so on. This plan, of course, 
presupposes a knowledge of the classification and principal forms of 
skin diseases, and to the reader who has such a knowledge the 
arrangement is in some respects convenient. Still it has the dis- 
advantage, that the information as to the treatment of particular 
diseases is often scattered over many chapters ; and were this dis- 
advantage not to a considerable degree made up for by a carefully- 
prepared index, its utility would be seriously impaired. 

Without containing much that is new, Dr Frazer's book lays 
before the reader, in a very accessible form, a large amount of 
usefcd matter ; and a formulary at the end of the volume contains 



1864.] ' DR WILLIAM PRAZEB ON DISEASES OF THE SKIN. 255 

the prescriptions referred to in the body of the work. He has, how- 
ever, committed a great mistake in not having been more careful as 
to the nomenclature of the drugs he adopted. We should not have 
quarrelled with him for not having in all cases adopted the terms 
of the British Pharmacopoeia, but in the case of such a substance as 
corrosive sublimate he was bound to do so. This Dr Frazer almost 
invariably calls the chloride of mercury, by which the reader would, 
of course, luiderstand calomel, were it not that what is stated as to 
the doses and properties of the remedy shows that he means cor- 
rosive sublimate. 

Dr Frazer is led at times to say something as to the symptoms 
and pathology of skin diseases. His remarks are generally judi- 
cious, but on the subject of scabies we cannot but look upon him as 
heterodoxical. He says, — 

" From a protracted series of inyestigations upon the subject of scabies, I am 
disposed to doubt that the acarus which so generally accompanies it is the real 
■cause of the eruption. These acari are a numerous family, ana abound on cheese, 
flour, raw sugar, and several other vegetable and animal substances ; and as it 
seems reasonable to conclude that there must be some common cause for their 
presence in every case, I feel convinced it will be found in their instincts leading 
them to settle upon the most appropriate feeding-grounds ; they require nitro- 
genous elements for then: support, for they never occur in pure sugar or other 
non-nitrogenous substances; and hence, in the cheese, the flour, and the scabby 
skin alike, they may well abound and multiply, for all offer suitable habitations 
for them, and ample means of living. That itch acari can communicate the 
eruption is no more than might be expected ; living upon the morbid secretion, 
theu: rough bodies and wrinkled limbs are well suited to transfer it to a fresh 
victim: vet it is certain that all persons are not equally susceptible of the con- 
tagion 01 scabies, which it appears to me must follow it these acari are admitted 
to be its only exciting cause ; and then itch would become as universal in its 
diffusion as other insect plagues, and possibly much worse, from the microscopic 
minuteness of the insect. There is another interesting fact in the history of 
itch, that the parasite is not always the same : in Norway a different creature 
of the &mily of mites has been discovered, though both there and in this country 
the eruption is found to present an identicafly similar appearance. I have 
further ascertained that the majority at least of those persons who have never 
been infected with itch are intensely susceptible of acquiring it ; whilst they 
who have passed through the unpleasant stages of an attack, and been thoroughly 
cured, show a comparative, it might almost be said an absolute, immunity from 
future infection. In making researches in this matter, it is alwavs necessary 
to discriminate between other pruriginous affections and that which b pre-emi- 
nently entitled to the term of itch, as there are no such limits to the reappear- 
ance of the former. The strange tendency which this disease shows to relapses, 
when insufficiently treated, and its indennite duration if neglected, are both 
true ; we cannot offer explanations of those circumstances, or of its rare occur- 
rence on the face, another problem of interest as yet unexplained ; thus it will 
recur again and a^ain from using clothes soiled by the patient himself; and, as 
an instance of this self-reinfection, I have seen severe pustular itch return more 
than once in a young child, until a pair of boots were destroyed to which the 
virus was persistently adhering.'* 

We conclude with an extract in which the therapeutic applica- 
tions of glycerine are clearly stated. 

" Glycerine has become largely employed of late years as a domestic remedy 
to heal superficial bums, excoriations, and erythematous affections, and /or 



256 DB WILLIAM FRAZCB ON DISEASES OF THE SKIN. [SEFT. 

applying to chapped and tender surfaces. Itisasedas^a therapeutic agent 
with two distinct objects ; primarily as an emollient, and still more usefully as 
a solvent and vehicle for different active substances. Its bland and unirritating 
properties render it a decided favourite ; it is used in several ways in treating 
cutaneous diseases ; undiluted it is gently rubbed over the affected part, or kept 
in close apposition with it by means of pledgets of moistened lint, or added to 
poultices to prevent them from becomm^ too hard and dry ; there is also a 
plasma or glycerole made resembling thick arrowroot jelly, by combining it 
with amylaceous substances, to prepare which a drachm or more of dry potato 
starch or arrowroot is blended with a little water, two ounces of glycerine added, 
and all triturated well together, and gently wanned until it oecomes a soft 
translucent mass : this plasma is found to relieve the heat and itching of many 
eruptive affections ; it adheres to the skin, keeps it always moistened, and 
preserves the surface clean and free from scabs or purulent incrustations ; it can 
also be applied as an efficient and cleanly poultice to delicate parts. The spe- 
cial advantages which glycerine plasma appears to have over ointments are its 
freedom from unpleasant odour, its being readily miscible with water, and easy 
to wash off, producing none of those stains and discolorations of the linen 
which greasy applications will do, but it is difficult to keep and liable to become 
mouldy. . . . 

" As a vehicle for more active medical substances, glycerine becomes of 
special service in practice ; and such are its remarkable solvent effects upon 
cnemical and vegetable bodies, that it is difficult at present to assign limits to 
its possible applications. When added to washes and lotions it will prevent 
their rapid desiccation ; and though it exerts little direct influence oeyond 
aiding in excluding the air and keeping the affected part constantly moistened, 
this itself proves of advantage, and will often heal simple fissures of the lips 
and chapped and tender nipples; in the latter case, when more energetic 
local treatment is considered necessary, the glycerine is medicated by dis- 
solving alum or tannin in it, or by the addition of an equal amount of 
brand]^. The fixed oils or greasy unguents are not properly miscible with 
glycerine, which after a time gradually separates from them like drops of 
water. This is more than compensated for by its dissolving the metallic 
salts, much in the same manner, and nearly to the same extent, as distilled 
water is capable of doing ; thus, for example, it freely takes up borax, and 
the solution, diluted to any requisite strength, is useful in those affections 
where alkaline lotions are of service, as for eczematous and impetiginous 
attacks, as an occasional wash, or applied constantly to the excoriated sur- 
face upon lint. Solutions containing iodine and iodide of potassium are 
prepared in every proportion, in glycerine similar to spirit of wine, and are 
preferable in many cases for external use, the absorption of the iodine being 
favoured by the persistent moisture of the glycerine. The great solubility of 
red iodide of mercury in this fluid enables us to employ it of any desired 
degree of concentration ; when dilute acting as a gentle local stimulant, or 
if strong as a powerful irritant and caustic. Glycerine is capable of taking up 
one fifth its weight of arsenious acid, or one half of chloride of zinc, forming 
energetic destructive compounds, likely to be of service in lupoid ulcers, etc. 
Preparations containing the salts of morphia, aconitine, and other alkaloids 
have already been employed with beneficial results in general practice, and are 
well suited for external use in treating cutaneous disease, as they can be 
prepared of definite strength, and are clean and manageable. Kreosote, 
carbolic acid, and tar are all soluble in glycerine, and mix thoroughly with the 
plasma of starch ; they are recommended in cases of psoriasis and inveterate 
lichen in the same manner as tar ointment ; this plasma also constitutes a con- 
venient vehicle for almost all these numerous substances ordinarily added to our 
ointments. M. Demarquay claims for pure glycerine the property of diminish- 
ing the amount of purulent secretion from ulcers, and of modifying the unhealthy 
character of many secreting surfaces, which, if established, would prove of 
great value in therapeutics. A few alone of its principal applications in skin 



1B64.] DB WILLIAM FRAZER ON DIBBA8E8 OF THE SKIN. 257 

diReases need be briefly mentioned ; in ery%ipehm it is AdTtsed to all«r the 
•malting ]>ain and Barnine sensations which attend the eruption, ana alao 
during the eraptive stage of snudl-pox, and whilst the pustules are becoming 
filled; for herpetic attacks, particnUriy herpes coster and circtnatus; to 
loosen the desquamations in the scaly affections, and relieve the distressing 
irritation of prurigo and lichen. For lupoid, strumous, rupic and similar 
ulcerations, where scabs and incrustations readily form, elycerine is recom- 
mended for softening and removing the purulent crusts, and uter their removal 
keeps the surface moist and healthy, it is applied on pledgets of lint, after 
the manner of water dressing, and covered over with gutta pereha paper or a 

layer of dry lint, to prevent it from soiling the dress, though the stains it { 

are easily removed by washing." 



l&nvt ^ivn. 



PERISCOPE. 



SURGERY. 

ON THE TBEATMENT OF ACUTE ORCniTIB BY PUNCTDRINO THE TESTICLE. 
BY HENBY SMITH. 

In July 1863, a young man presented himself amongst the out-patients at 
King*8 College Hospital with gonorrhceal orchitis in a very acute form. The 
pain was unusually severe ; and, on examining the organ, it appeared to me 
that suppuration Kad taken place, the sense of fluctuation bcuig, as I thought, 
distinct. With a view of evacuating the pus, I took a bistoury, and made a 
free and deep incision into the supposed abscess ; but, to my astonishment and 
dismay, not a drop of matter escaped — only a little serum and blood. The 
Cubes, however, of the testicle shot out, as it were, from the wound, forming a 
protrusicm the size of a nut. Some pressure was applied by means of strips of 
plaster, and the patient was sent away. 

Two days afterwards the man presented himself, but in a very different eon- 
dition. He was quite free from pain, all the redness and most of the swelling 
bad disappeared, and on taking off the strapping it was foOnd that the protru- 
sion of the tubes of the testis no longer existed. 

This ease, which was somewhat annoying to me at the time, suggested some 
aerious reflections in reference to the speedy relief which had resulted from a 
practice which in reality was the effect of an error of diagnosis on my part. 
Was the sudden relief here a mere accident? or, if not, to what could it be 
due? The quantity of serum and blood abstracted was so small that the ces- 
sation of pain and diminution of swelling could hardly be due to this cause ; 
but it struck me forcibly that the free division of the fibrous tissue enveloping 
the body of the testis, and the consequent removal of tension from the organ, 
was the secret of the success, provided it was not a mere accident. 

Influenced by this reasoning, and by the result of this case, 1 determined to 
try the effect of puncturing the testis in similar cases ; and in the next case of 
acute orchitis which presented, I made a deep and free incision with a sharp 
marrow bistoury, emitting about half a teaspoonful of serum and several drachms 
•of blood; and no other treatment beyond a little of the common aperient 
mixture was supplied. The result here was as successful as in the K>nDer ; 
and as cases presented themselvea, I adopted the same plan of treatment, 



258 PERISCOPE. [sept. , 

reaerying it, however, especially^to those instancea where the swelling and 
pain were verv great. After the*trial in a few cases, it was found that the 
success attending this practice was such as to lead me to adopt it as the usual 
treatment of acute orchitis ; and during the last twelve months I have probably 
treated in this way upwards of twenty cases, with such results as have astonished 
both myself and those numerous pupils who have witnessed the practice. 

In nearly every case so treated — and I have purposely selected the most 
acute — the patient has experienced the most striking relief before he has left 
the out-patients' room ; and on the next visit, forty-eight hours afterwards, the 
contrast presented is so remarkable that the superiority of this plan over the 
old-fashioned modes of treatment is at once impressed forcibly upon the minds 
of those even who would naturally be prejudiced against so apparently heroic 
a treatment. The speedy subsidence of all the acute symptoms is due entirely 
to the puncture of the swollen and inflamed organ, for t have taken especial 
care not to prescribe anything else except a little of the common white mixture, 
or perhaps the use of tne ordinary lead lotion, and this chiefly to please the 
patient. 

We all know what a terrible ordeal of violent remedies a patient with acute 
inflammation of the testicle has to undergo. In the first place, he is obliged 
to lie in bed for several days ; a large number of leeches or the constant appli- 
cation of ice are necessary to relieve the pain ; and at the same time the unfor- 
tunate wretch is compelled to undergo the process of severe purging and 
continued nausea, by repeated doses of salts and tartar emetic, before any 
decided mitigation of his symptoms ensues ; and two or three days mostly 
elapse before he recovers from the depressing influences of these several 
remedies. Lastly, the unfortunate organ has to be submitted to the tender 
mercies of a dresser, who, however skilful he may be, cannot help putting the 
owner of it to severe and prolonged torture whilst he is obeying the injunctions 
of his superior to *' strap testicle." 

Now for all this I venture to submit the plan now proposed, and one which 
I should call a '^new" one; but it is venturing on dangerous ground to call 
anything new nowadays. Moreover, my old assistant and our present house- 
surgeon, Mr Richmond, informs me that when he was in Paris two years ago 
he saw the same method of treatment adopted there ; but I never heard of it 
before I resorted to it, and the practice in my hands was entirely due to the 
accident I have related above. 

Of course several of my friends and pupils have ureed objections against this 
plan of treatment, and su^ested serious results, in the form of suppuration of 
the organ, impairment of its function, hernia testis, and fistulous sinuses ; but 
none of these have I witnessed. It is very natural and proper to make these 
objections, for we have always carefully avoided the possibility of a puncture 
of the testicle when using a trocar for paracentesis of the tunica vaginalis, and, 
indeed, I have witnessed violent suppuration of the testis speedily ensue from 
this accident ; but it must be borne m mind that wounding of a healthy testicle 
with a large and blunt instrument like a trocar is a totally different thins from 
a careful incision made into the highly inflamed organ by a thin sharp buide. 

The only inconvenient result I have witnessed from this treatment was the 
following : — ^/Vn incision was made into the testicle of a middle-aged man, with 
the usual relief, but in a few days the scrotum began to swell, great pain was 
experienced, and the man was taken into the hospital. The objectors to the 
mode of treatment suggested all sorts of disasters, in the shape of suppuration 
of the testicle, etc., but on careful examination it was ascertained that the 
swelling consisted of a large and rapid effusion of fluid into the tunica vaginalis, 
which was at once evacuated, with speedy relief to the patient. In another 
instance I made the incision much deeper than was necessary, carrying the 

Eoint of the knife nearly to the back of the organ. As much as ten ounces of 
lood were lost ; but the testis was violently i^amedand swollen, and the only 
effect of the accident was to make the patient somewhat faint, but at the same 
time to give more speedy and effectual relief than usual. 



18e4.] SUBQERT. 259 

Thi8 circamBtance may lead one to the belief that the relief i« dae solely to 
the escape of blood from the pancture ; bat this view is inconsictent with the 
fact that great relief is given when only a few drachms of blood, miied with 
serum, are discharged. JDoubtless the direct withdrawal of blood from the 
highly mflamed testicle is of service, but my own view of the matter is, that 
the relief is in a great measure due to the withdrawal of the tension from the 
body of the testis by free division of the tunica albuginea. 

Whatever may be the precise manner in which the good results are pro- 
duced, there is no doubt of the fact, and I would earnestly suggest to surgeons, 
especially to my colleagues, the assistant-surgeons of the hospitals, who treat 
the majority of cases of orchitis, to adopt the plan proposed, rather than be 
aubmitting their patients in a routine war to all the horrors of the middle 
passage, from tartar emetic to strapping of the testis. 

F,a, — Since the above was written I have seen one of my old pupQs who 
has been spending the last six months in the Paris hospitals, and ne informs 
me that the ordinary practice at the Udpital de Midi in cases of acute orchitis 
is to make a puncture in several places with a lancet ; the instrument is not 
carried into tne body of the testicle, but simply through the tunica albuginea. 
He describes the plan of treatment as most successful. — The Laneei. 

PBRMANQAMATE OF POTASH IK GONORRB(EA. 

For the last two years I have frequently employed the permanganate of 

Sotash as an ii^ection in the treatment of gonorrhoea, and the constant success 
erived from its use has been extremely satisfactory. My usual method had 
previously been to administer, first, a hydragogue cathartic, then to give a 
mixture of cubebs, copaiva, nitre, etc., with injections of sulphate of zinc, 
tannic acid, etc. But since employing the permanganate my treatment has 
been much more circumscribed, for with this remedy alone I have frequently 
cured very bad cases in forty-eight hours, and this too without its bein^ 
followed by any evil effect from the sudden arrest of the discharge. My usuiu 
mode of treatment, however, is as follows : — Jjt Potassse bitart. V)j. ; podophyllin, 
gr. j. M. In chartulas quatuor dividendus. S. One every two hours until 
free catharsis is produced. After which : — 9 Potassse permangan. gr. vj. ; aqusa 
fontan, J^. M. S. To be used as an injection three times a-day. I direct 
at the same time the free employment of mucilaginous drinks, as althaea, ulmus, 
acacia, etc., and put the patient upon a non-stimulating regimen. 

Out of sixty-four registered cases this course of treatment has failed in but 
two instances. And I find that recent attacks usually become arrested by it 
after from three to six injections. I have found it advisable to continue the 
demulcents for at least a week after the cessation of the discharge. In none 
of all these cases was the injection continued after the fourth day. When 
accompanied by chordee, I usually employ the following : — 9 Lupulin, 3jss. ; 

Sttlv. camphorae, ^j ; micse panis, q.s. M. Ft. mass in pilulas, xvi, dividenda. 
. Two, three, or four on going to bed. I think that the permanganate of 
potash is a remedy deserving of more notice than physicians have hitherto 
given it, and I hope that my experience may produce for it a more extended 
trial in cases of gonorrhoea. — Dr J, G. Eich in Canada Lancet. 

CASE OF EXTREME SQUINT CUBED, WITHOUT OPERATION, BY THE USE OF 
PRISMS ; WITH CLINICAL REMARKS. BY MR ERNEST HART. 

The following case is one of interest, as belonging to a class of instances of 
aquiut in which, by a careful distinction of causes, the deformity may be treated 
npon a scientific basis, and radically cured by a simple adaptation of optical 
means without any operation. Mr Hart observed m reference to it, that a 
careful study of the origin and nature of various forms of squint shows that the 
treatment must, to do justice to the patient, be almost as much optical as 
purely surgical ; and there is a large proportion of cases in which merely 
optical means succeed perfectly, either in averting the formation of a perma- 
VOL. X.— NO. m. ' 2 L 



260 PERISCOPE. [sept. 

nent squint, in caring it when the proper glass is applied early, or in prevent- 
ing relapse after operation. 

J. C, aged twenty-seven, a sailor, of good general health, and had always 
possessed excellent sight. In May 1863, he had a severe attack of rheumatic 
fever ; various joints were attacked in succession, and he lav for nearly two 
months helpless in bed . Towards the end of the attack the eyes became affected : 
the light became painful to them ; the eyeballs he describes as havmg become 
blood red, and acutely painful, the pain being severe over the brow, and dart- 
ing through the head from the frontal region. The face was blistered by the 
abundant and acrid lachrymation. Thus there seems to have been an acute 
rheumatic ophthalmitis. He recovered well, and is not aware that there were 
any immediate traces left of the disease. He went a voyage to the Cape, and 
came home in satisfactory health ; but in the subsequent voyage, in December 
1863, he became aware of a certain dimness and confusion in looking at 
objects, -a difficulty in measuring dbtances, and in defining the outlines of 
thmgs and persons before him. This came on, he thinks, quite suddenly; and 
in the course of the day he found that he had a decided convergent squint of 
the right eye, and that he had lost control over the movements of that eye. 
He consulted Mr Hart in the middle of January last. 

Mr Hart found then a convergent squint, monolateral, of the right eye, per- 
manent, and due to paralysb of the external rectus. The visual powers of the 
two eyes, tested separately, were very nearly equal. There was no dilatation 
or semi- dilatation of the right pupil ; no drooping of the lid. The latitude of 
accommodation was equal to that of the left eye. The patient suffered greatly 
by the constant confusion arising from the double set of images which the 
incongruous eyes received. He was frequently unable to distinguish between 
the true image and its ghost, and, besides the giddiness and confusion thus 
occasioned, felt himself in danger in walking the streets. 

Mr Hart called the attention of the class especially to the case as one in 
which, from the positive and negative data above mentioned, the cause of the 
squint might be accurately determined. He referred it to insufficiency (paresis) 
of the right external rectus. The normal action of the other muscles of the 
eye and eyelid and of the iris, excluded cerebral causes; while the absence of 
far-sightedness or short-sightedness in any marked degree, and the healthy 
appearance of the internal fundus of the eye revealed by the ophthalmoscope, 
excluded dioptric or retinal disorder from the etiology of the case. The cause 
being thus determined, it remained to decide on the remedy. Mr Hart pointed 
out that in this case the cause of the double images which occasioned so much 
distress was that incon^uous portions of the two retinse were, by virtue of the 
displacement of the axis of the strabismic eye, impressed with the respective 
images of each object seen. This might be remedied, then, by the use of a 
prismatically ground spectacle-dass, with the base turned in the direction 
opposite to that of the squint ; for such a glass has the power of causing a 
deviation of rays of light incident on its base, which may thus be used to 
deflect the rays proceeding from objects looked at, so that they may, in the 
case of the squinting eye, be made to fall upon a part of the retma couctuous 
to that which receives them in the normal eye, and thus binocular vision be 
restored. In fact, a prism may be used thus to fuse and destroy double 
images, just as, conversely, with healthy e3res, it is sometimes used in sport to 
produce them. Taking a series of prismatic glasses ground to scale, Mr Hart 
then essayed them with this patient before the class. A glass ground to an 
angle of twelve degrees placed before the deviating eye so lutered the direction 
of the images which it received as to fuse the double images into one. This, 
however, would only have removed the visual uiconvenience without curing 
the squint. By now selecting a glass of ten degrees the images could be nearly 
fused, but not quite ; and then the horror of double images, which is instinctive, 
caused an involuntair effort of the semi-paralytic and enfeebled rectus extemus, 
which just succeeded in drawing the eye so iar further outward as to compen- 
sate for the diminished angle of the prism, and fuse the double image. This, 



1864.J SURGERT. 261 

then, was the gUus selected for the pfttient to wear ; for by the aid of this 
glaas the enfeebled miude was, as it were, gymnasticalJy eiercised and 
strengthened. The fusion uf images was not effected without an effort some- 
what painful, and which could not long be sustained. Mr Hart therefore 
directed the patient to employ the glass at intervals only during the day, 
gradually lengthening the period of eiercise. In the course of seven days he 
had made considerable proeress, could wear the glasses much longer at a time, 
and fuse the images more thoroughly and with less effort. He was then very 
anxious to rejoin his ship. Mr Hart therefore fum ished him wit h glassetc of eight, 
six, and four degrees respectively, so that as the muscle became stronger a 
corresponding^ly greater effort might be required of it ; the glasHCs fulfilling a 
true gymnastic as well as optical function, and acting just as dumb-bells of 
graduated weight, with appropriate exercise, may be made to act, in dealine 
with enfeebled muscles in other parts of the body. The patient was desired 
to communicate the result, or to show himself on his return. Recently the 
man presented himself quite cured. This cure was effected in the course of 
eight weeks. And in June he wrote to say that his eyes are now as good as 
ever, that the movements of the two are synchronous, and vision normal. 

In another patient, now under treatment, in whom the squint was also mono- 
lateral and permanent, and on whom this method of treatment wUl be employed, 
the paresis of the abducens has followed on extreme debility after menorrhagia 
and lactation. Mr Hart observed that it was essential to the good repute of 
this method of treatment that it should be employed with discrimination, and 
as the result of a careful diagnosis. It would be useless to attempt to cure by 
this means an alternating concomitant squint with hypermetropia, or a stra- 
bismus from active organic cerebral disease. But in every case of squint, the 
divergence of the eye must be regarded as a symptom, to be treated differently 
according to the nature of the various causes from which it arises. Sometimes 
a squint was the first indication of insidious meningitis in a chUd, of which he 
cited a remarkable case that he had Litely seen in conjunction with Mr Paul 
Jackson : then the ophthalmoscopic indications are of the highest value for 
the purposes of general treatment, and the squint must be disregarded. Yerf 
frequently a slight squint or confused image, due to insufficiency of the S3mergic 
action of the ocular muscles, was the first symptom of an impending acute or 
chronic cerebral disorder, and the ophthalmic surgeon had to yield place to the 
physician. In either of such cases to operate would be useless cruelty. 
Another set of cases were those of which the above-quoted is a fair type. 
Then came the large class, so admirably investigated by Donders and Von 
Graefe, in which squint is due to hypermetropia of the eve leading to excessive 
contraction of the internal rectus : in such cases, the degree of squint being 
measured, the division of the tendon, carefully adjusted, was followed by the 
best results. But to make strabotomy yield the almost uniformly successful 
results which might now be obtained from it, it was necessary to exclude all 
the cases which might be cured by other means, and also those which were 
incurable by any means. The apphcation of a prismatic spectacle glass in the 
class of cases above defined was most successful, if carefully carried out and 
used for fit cases. — The Lancet. 

M. CHABBAIGNAC'B drainage TUBEg. 

The greatest and simplest and most generally useful of M. Chassaignac*s special 
modes of treatment is the draining tuhe^ and we doubt whether the professional 
mmd on this side the Channel is yet sufficiently alive to its merits. Most of 
our readers have heard of it— a little india-rubber tube perforated with holes, 
and introduced into suppurating cavities, in order to provide for the gradual, 
constant, and immediate discharge of all secretion without admission of air. 
Any one who follows M. Chassaignac for a few mornings, and hears him order 
unpen de drainage will see the class of cases to which the method is applicable ; 
and if he shares our good fortune, he will see some of the results, and hear a 
clear exposition of the very simple principles on which it is based. As the 



262 P£BISCX)PE. [SEPT. 

visiter follows from bed to bed amongst the chronic snrffical citses attended 
with suppuration, he will see here a thigh, there the back or the breast, or 
possibly a tarsus swelled into that too-familiar lump indicative of scrofulous 
caries, and in each case one, two, or perhaps half a dozen of the tiny black tubes 
passing right through the diseased part ; in fact (in the case of a diseased 
tarsus, for example), wherever there is, or threatens to be, a sinuous opening, 
there M. Chassaignac orders un peu de drainage. As he passes round in hii 
visit, the tubes are examined to see if they flow freely, and the edges of the 
aperture are just touched with a solution of lunar caustic, to supply which, the 
clinical clerk follows with a bottle of the solution, and a hanaiuf of wooden 
'skewers armed with a little piece of cotton wool, which are rapidly used and 
thrown aside. This protects the orifices from ulcerative action, and from 
possible contamination from without. The principle of the drainage system 
18 clear enough. A bone is carious ; particles of the tissue in a state of decay 
are cast off, and mingled with the exudations of the surrounding. parts, they 
form a petty swelling. This cannot be absorbed in most cases ; and it acts 
as a source of irritation to the neighbouring tissues, and tends to spread the 
morbid action of which it is the result. In ordinary practice, when it has 
accumulated in quantity to form an abacesSy it is discharged by incision, if need 
be. But fresh collections form, and discharge themselves in other tracks, till 
the whole member is riddled with unhealthy sinuses. Here drainage does 
well what the best efforts of Nature point to, but accomplish ill. It provides 
at once an exit for discharge and necrosed particles, through a tracK which 
the surgeon chooses, and which does not add to the severity of the original 
disease, for the hole made by the fine trocar, which introduces the tube, is a 
very slight injury. But this slight wound accomplishes all that can be done 
by A free incision. Again, instead of waiting till extensive disease has resulted 
in large abscesses or in a heroic operation of excision, or of gouging, these 
little tubes do the work of the gouge piecemeal and incessantly. We do not 
say that English surgeons are unacquainted with the tubes, but they do not 
know enough of their preventive functions. Surgical books contain cuts of 
gouges, and of oetecftritea for cutting or grinding away carious bone, when the 
case has become a matter of life or limb ; but they do not tell us to bore a 
tarsus with the little tube, which shall stop the mischief at its outset. As to 
the results, we saw at the clinical lecture patients presented cured, who had 
suffered from lumbar abscess following vertebral caries, and from various other 
scrofulous diseases of bone. The exposition of the method and of the result 
was admirably given, showins immense shrewdness and ingenuity, together 
with that thoroughly practical seeking for remUe^ which we are apt, in these 
isUnds, to think peculiarly our own. — Medical Timee and Gazette, 



MIDWIFERY. 

ON PLACENTA PRiSyiA. BY ROBERT GREENHALGH, M.D. 

At a meeting of the Obstetrical Society of London, held on the 6th of July, 
Dr Greenhalgh read a paper on the subject of placenta prssvia. 

The author first alluaed to the large mortality both to mothers and children 
(one in four and a quarter of the former, and about two-thirds of the latter), 
which he attributed mainly to the severe and repeated losses of blood, to the 
delay in effecting the delivery, and the method of turning usually had recourse 
to in these ca^es. He then gave the details of twenty-four cases which had 
occurred in his own private and consulting practice between the years 1842 
and 1864. He placed before the Society several statistical tables, chiefly 
taken from Dr Read^s work, to show, in addition to other facts, that the ex- 
pulsion of the child generally takes place before the full period of utero-gesta- 
tion, — premature labour being the rule and not the exception ; that nature, 
unaided, frequently terminates the delivery with safety both to mother and 
child ; that complete and partial artificial separation of the placenta before the 



1864.] MTDWIFERT. 263 

birth of the child haa failed in namerons cases to arrest the hsemorrhage ; and 
that these methods and turning had proved most nnsatisfactory in their results. 
Having dwelt at some length upon these several points, he strongly advocated 
a close observance of the way in which nature terminates these cases with 
safety to mother and child. Having specified the result of his observations on 
that head, he confidently recommended the following plan of treatment, which 
had proved, as far as the limited number of cases could prove, in his hands and 
in those of others, far more successful both to mothers and children than any 
other method hitherto devised. It was as follows: — Isty That in case of 
haemorrhage, whether profuse or otherwise, occurring after the commence* 
ment of the seventh month of utero-gestation, ascertained to be due to 
placenta prsevia, artificial premature labour should be induced at once, or as 
soon as the condition of tne patient will admit of it. 2cKy, That in order to 
effect that end without loss of blood, an air-ball, covered with spongio-piline. 
be passed, collapsed, into the vagina, and then inflated so as effectually to fill 
that canal, while a bandage is placed firmly round the abdomen ; at the same 
time the ergot of rye and borax are to be administered in repeated doses. 
He further recommended as aids, stimulating enemata, with tincture of nuz 
vomica, galvanism, and friction over the abdomen. The author concluded by 
condemning, in the strongest terms, the use of general hygienic means and 
hemostatic remedies over days and weeks in these cases, wnich course, he was 
firmly convinced, was the cause of many valuable lives being lost. 

Dr Bamea observed that, agreeing senerally in the principle that labour 
should be brought on in cases of severe hsBmorrhage from placenta prsevia, — a 
principle, he believed, commonly acted upon in liOndon, — be could not assent 
to much of Dr Greenhalgh*s reasoning, or concur in approving his plug. His 
statistical reasoning was open to criticism. He assumed two postulates ; first, 
that the mortality of placenta prasvia was 1 in 4i ; secondly, tnat the mortality 
from inducing premature labour was 1 in 53 ; and he drew the extraordinary 
conclusion that by always inducing labour we might substitute the low mor- 
tality of premature labour induced under selected circumstances for the 
assumed heavy mortality of 1 in 4^. Now both the postulates were false, and 
the conclusion was manifestly illosical. The mortality of 1 in 4} drawn from 
Pr Read^s tables was a most unfair representation of the results of modem 
obstetricv. He (Dr Barnes) had analyzed his own cases. Since the publica- 
tion of his Lettsomian Lectures, 59 cases had come under his own observation ; 
and he drew 24 from other sources, roost of these last being treated upon his 
(Dr Barneses) principles. The deaths were 6 only, or 1 in 14. And if he were 
to follow Dr (ireenhalgh in striking out the fatal cases on the ground that 
treatment was too late, he might show statistical results very mr superior. 
He should have, not 10 successful cases, but 77. Two of his cases aied of 
pysemia, having been treated by forced delivery, — ^that is, in direct opposition 
to his principles ; 2 were moribund when seen, and 2 were hopelessly anemic. 
He haa taken all cases as they occurred in his books without selection or 
arrangement, yet 26 cases fell as an uninterrupted series of recoveries, which 
he might fairly place against Dr Greenhalgh^s selected 10. Then as to the 
mortality in premature labour. Premature labour was induced under selected 
circumstances to avoid dangerous complications. Such cases were not to be 
compared with labours forced upon us by the flooding of placenta previa. 
This Dr Greenhalgh disregarded. But surely placenta previa went for some- 
thing. Then the children. Dr Greenhalgh had been fortunate. In his small 
series of 10 cases he had 8 living children. He (Dr Barnes) ventured to say 
that a larger experience would modify this result. Many dangers surrounded 
the child m placenta previa : cross births, funis presentations, immaturity, and 
asphyxia in utero *, some were bom putrid. His (Dr Barnes's) plan was emi- 
nently adapted to secure the child. But his mortality was '63. The very 
method of Dr Greenhalgh of bringing on premature labour must of itself often 
destroy the child, for the floodings would come on at six and seven months. And 
in some cases flooding did not occur until the end of gestation. These were often 
the most dangerous. Yet here Dr Greenhalgh's plan was not available. And 



264 PERISCOPE. [sept. 

what was Dr Greenlialgh's plan? The use of a fxiginnl plug, not differing 
essentially from the colpearynter of Braan. It acted like all other yaginal 
plugs, by exciting uterine contraction, if the uterus was excitable. But unfor* 
tunately in the worst cases the uterus was paralyzed. In these, where art 
was most necessary, the plu^ was useless. He was surprised to hear Dr 
Greenhalgh underralue rupturmg the membranes. This simple method was in 
many cases quite sufficient, and no method was long serviceable without it. 
If in combination with rupturing the membranes, the placenta was detached 
from the cervical zone, so freeing the cervix, the cervix then artificially 
expanded by his cervical dilators, and the bimanual method of turning resorted 
to, he was confident, from large experience, that a greater measure of success 
would be obtained than by any other especial method. He took that oppor* 
tunity of stating that the first published case of the use of the intra-uterine 
dilator in placenta prsevia which attracted his attention belonged to Mr Jardine 
Murray of Brighton. 

Dr HaU Davis remarked that he had little faith in statistics of placenta 
prsevia representing a mortality of 1 in 3 or 4 from that complication, 
knowing that former statistics to that effect had included cases originally pub- 
lished, not to show the average mortality, but as selected instances for the 
most part hopeless when first brought under medical observation, and intended 
to prove the fatal tendency of this complication of pregnancy if not timely seen 
to. He would also observe that we are not left without authority, laid down 
in lectures and works of reputation, to convince us of the dangers of delay in 
placenta prssvia, and guide us to efficient treatment. He might refer, for 
example, to the lectures of the late Dr D. D. Davis at University College from 
1828 to 1841, and to his esteemed System of Obstetric Medicine, which taught 
no temporizing treatment, but, on the contrary, the necessity of early and 
active mterference, while at the same time pointing out the hazards of a 
forced delivery through a rigid os uteri. As to his own experience, he might 
state that in tne Royal Maternity Charity alone he had had, from 1842 to 1862, 
as physician of the western district, 24 cases of placenta prsevia. In that 
number twenty-two mothers were saved, and the two deaths would have been 
averted had the injunctions given been observed. His treatment had varied 
with the case. Thus in partial placenta prsBvia he had found the simple dis- 
charge of the waters usually sufficient. When the flooding has not been thus 
arrested, and delivery has been impracticable by reason of the small size of 
the uterine orifice, he has plugged the vagina impactedly with sponge, or with 
a sufficient quantity of other suitable material at hand. He has then waited 
in security for the first opportunity of acting if necessary. In many cases, on 
withdrawing the plu^ tlie head was found descending, and the birth was 
quickly completed without further aid. In cases of entire placenta pnevia, 
when the os uteri would not admit of delivery, he also resorted to the plug, 
and of similar materials as before, believing such a plug, from its solidity, when 
efficiently applied, to be far superior to any elastic dilator. After from two to 
six hours he was generally enaoled to remove the plug and deliver by turning. 
In this operation ne preferred to pass his fingers in b3r the side of the placenta, 
where it might already be detached, to perforating its centre, as some have 
recommendea, as this fatter mode necessitates a more considerable injury of 
the placental vessels and further hsemorrhage. In the operation of turning, 
it had been his usual practice to fix the uterus by the right hand applied 
externally on the abdomen while turning with his left hand. To Dr BJcks, 
however (Obstet. Trans., vol. v.), were we indebted for a definitely combined 
mode of external and iiUemal version by acting on the opposite poles of the 
child, the breech above being depressed by the external hand, while at the 
same time the presenting head is pressed upwards and to its own side. Then 
the feet are lowered to the os uteri, and one or both brought through ; the 
risk, so especially great in flooding, of passing the hand into the cavity of the 
uterus being in this way avoided. In conclusion, he might say that, while he 
differed from the author on the points to which he had referred, he fully con- 



1864.] MIDWIFERY. 265 

curred with him, as all jadicioiu practitionera mint do, that to delay efficient 
interference in this complication is most hazardous. 

Dr J. Braxton Hick$ quite agreed with Dr Greenhalgh as to the necessity of 
inducing labour in placenta nravia as soon as arrangements could be made, 
which he believed to be the plan adopted by all who saw much midwifery in 
this city ; it was the practice he had always adopted. With regard to the 
statutics quoted from Dr Read's work, he quite agreed with Dr Barnes as to their 
want of value. All large ^oups of statistics were utterly useless as a guide of 
any particular practice. It was absolutely essential that the details of the 
cases should be known. In the tables presented to the Society it was impos- 
sible to say what were the surroundings of the patients ; whether, in fact, they 
had died from the operation, from the hssroorrhage, or from the subsequent 
calamities to which it was known cases of placenta nrevia were eiposed. 
How, therefore, could we tell the value of any particular plan of treatment 
without this information ? He considered that when it was said the death- 
rate was 1 in 4^, there must be some mistake as regards present practice. In 
the Guy*s Hospital Charity it was for nine years at 1 in 74. He also was 
obliged to differ from the assertion that the life of the child was not influenced 
by placenta prsevia. That it was so he had no doubt ; for in half of the cases 
he had seen where it was made out clearly, the child was known to be dead 
before any operation was attempted. He hoped the author would have alluded 
to the plan which he (Dr Hicks) had recommended in his recent paper on 
** Combined Version,'* because he felt sure that it was a very useful one, and 
not difficult to any one who would take the trouble to learn it He had known 
at least nineteen cases, many of them very severe, in which it had been used, 
with only one death, and tbiat arising from extreme haemorrhage before seen, 
and which could not be put down to version. In all his cases there had been 
immediate cessation of bleeding as soon as the breech was in the os, and he 
had found that almost in every case labour pains expelled the child within two 
or three hours from the commencement of the operation. This point it was 
important to know in order that we mi^ht make our arrangements accordingly. 
The child was a most efficient plug, and it could be brought down as soon as 
the OS would adniit a linger or two. With regard to the small size of the os 
preventing turning in the above-mentioned mode, he could say it must occur 
Dut seldom ; when it did so, the detachment of placenta romid by one finger 
generally liberated it considerably, enough at least to introduce two fingers ; if 
not, the elastic bags could be used with much advantage. We must judffe of 
treatment by its practical application : our hands we have always with us, 
whereas if called to a case at a distance from home, or in great hurry, it would 
be impossible sometimes to obtain the plug now shown. The effect of version 
upon the life of the child he could not compute. Doubtless, cephalic was the 
best presentation ; but he had not found in his cases any ereat mortality. The 
important point was not to hurry the case after the breech was in the oh. The 
child was generally destroyed by drawing it down before the os uteri was open 
sufficiently. When the breech was in the oSj the case in almost every instance 
might be left to nature, adopting the rule as m breech cases. 

Dr Graily HewiU considered the principle enunciated in the paper now read, 
of the necessity of interference in cases of placenta previa, to oe one of great 
value. This principle had never been sufficiently insisted on, and although 
admitted by men of experience, it had not been laid down as a principle in the 
obstetric text-books. He might mention that two years ago a gentleman in 
practice in Yorkshire had, in conversation with him, alluded to this very 
subject, having lost a patient from a suddenly recurring hsBmorrhage due to 
placenta prsevia. The gentleman in question had hesitated, on the occurrence 
of the first haemorrhage, to induce premature labour, not finding such practice 
sanctioned by the text-books, and the patient, living at some distance, had 
perished when the haemorrhage recurred two or three weeks later, before 
assistance could reach her. Doubtless there were cases of this kind occurring 
from time to time, and which would have been saved by interference. He 



266 PERISCOPE. [sept. 

considered, therefore, that the expression of the opinion of the Society on this 
subject would have a most beneficial influence, and that patients known to 
have placenta preevia would not be left liable to perixh at any moment from 
haamorrhage. With reference to the particular plan of treatment advocated by 
Dr Greeuhalgh, which was a moditication of the " plugging " system, he had 
some remarks to make. It was to be recollected that m cases of placenta prsevia 
we have two lives to consider — ^that of the mother and that of the child. 
What is best for the one is not always the best — ^nay, it is frequently the worst 
for the child. The safety of the child lay in speedy delivery ; the safety of 
the mother in preventing haemorrhage. Plugging the vagma, artificial or 
partial separation of the placenta, were measures calculated to stop haemorrhage ; 
Dut such treatment, unless accompanied with speedy delivery, was prejudi- 
cial to the child, whose vitality was necessarily destroyed by separation of the 
placenta to any considerable extent, with or without concurrent external loss 
of blood. On referring to Dr Greenhalgh's statistics, it would be seen that 
although the mortality to the mother was, on his system of treatment, low, 
yet that the percentage of stUl-births was high, and the plan in question was, 
therefore, open to this serious objection. He (Dr Hewitt) was quite aware 
that it was impossible to legislate equally well for all cases, the circumstances 
of each case being, to a great extent, peculiar ; but any generally accepted 
system of treatment must have in view the preservation of the lives of both 
mother and child. Rapid natural delivery best fulfilled all the indications, and 
this should be the object sought to be attained in the treatment of these 
dangerous cases. In a certain number of instances rapid natural delivery was 
not possible, and under these circumstances the operation of turning offered 
the best alternative. The extraction of the child should not be performed too 
soon after the version, unless the bleeding still continued ; for until the os was 
tolerably dilated, the neck of the child was likely to be so tightly caught by 
the OS as to prevent extraction. When the foetal heart was b«atin^ very 
slowly, rapid extraction of course afforded the only chance of preserving its life. 
In conclusion, he considered the Society under obligation to Dr Greenhalgh 
for his very practical and able paper. 

Dr Beatty (of Dublin) in reply to an invitation from the President to address 
the Society on the subject, said that he addressed the Society under very 
senous difficulty ; for not having had the advantage of hearing the paper now 
under discussion read at the former meeting, he did not well understand its 
bearings ; but as well as he could collect from the speakers who had preceded 
him, he inferred that there were two points particularly dwelt upon by the 
author. The first was the time at which we should mterfere in cases of 
placenta prtevia ; and the second, the kind of assistance most proper to be 
given. It appeared to him (Dr Beatty) that the author of the paper recom- 
mends delivery as soon as possible after the case was fully made out. In this 
respect there was not much difference between his and the practice very usual 
in Dublin. We wish to finish the case as soon as possible ; but it must be 
recollected that in many cases speedy delivery was impossible, for occurring 
as the haemorrhage most usually does for the first time in the eighth month, or 
even earlier, when the os uteri was little disposed to relax, it not unfrequently 
happened that the os uteri was so rigid that delivery could not be attempted. 
We must then temporize, and by means of position, plug, cold, etc., endeavour 
to gain time, and save the patient from loss of blood as much as possible. He 
had spoken now of cases in which there was complete covermg of the os 
uteri by the placenta; but in cases of partial covering, where we could 
feel any portion of the transparent membranes, the practice was to rupture 
them at once, and discharge the liquor amnii. When this could be accom- 

Slished, we feel pretty easy about the case. The head of the child comes 
own, and by pressure on the placenta, prevents any further loss of blood. 
If the uterus was not disposed to act vigorously, its action was quickened by 
the ergot of rye. He always depended upon the infusion of the powder made 
on the spot. It was a meaicine that required great care for its safe preser- 



1864.] MIDWIFEBT. 267 

▼atioD. He never went out without a drachm of the powder in his pocket- 
case. It was pat up in metallic paper, so as to prevent the absorption of the 
oil by ordinary paper. It shoula not be kept more than two months in the 
case. I£ not used before then it should oe replaced by another drachm. 
When used it was infused in four ounces of boiling water, and half of it, 
powder and all, given at once, and the other half in a quarter of an hour. 
When treated in this way the medicine had never failed him. If the case was 
one of complete covering of the os uteri, we watch the earliest moment at 
which the os uteri was dilatable, and then proceed to deliver the patient by 
turning the child. From these few hurried observations it appeared that the 
practice in Dublin does not much differ from that laid down by the speakers 
who had preceded him (Dr Beatty) in this debate. 

Dr Woodman mentioned some cases in which he had observed the good 
effects of the treatment recommended by Dr Barnes. 

Dr Gervis remarked that the observations of Dr Beatty relative to the 
firequent necessity of " temporizing " in cases of hflsmorrhj^^e from placenta 
prsBvia, where there existed a rigid condition of the os and cervix, illustrated 
the main point at issue between Dr Greenhal^h and Dr Barnes. Dr Green- 
haleh in such cases advised the use of the vagmal plug, an abdominal bandap^e 
with which to maintain pressure on the uterus externally, and the adminis- 
tration of ergot; while Dr Barnes maintained that his cervical dilators by 
themselves sufficiently superseded the use of the plug, the bandage, and 
the ergot, inasmuch as wniie they were dilating the os and cervix, thej 
simultaneously prevented hsemorrhage and excited uterine action. In this 
estimate of their utility Dr Gervis entirely concurred. Instead of temporizing 
in any manner, or trusting for the accession of labour to the use of ergot, by 
these bags you obtained full control of the case from beginning to end ; and 
after adequate dilatation of the os, you could either separate the placenta 
from the orificial zone, rupture the membranes, and then, if that sufficed to 
check the haemorrhage, leave the case to nature, or by the bimanual method of 
version, complete it at will. It was not, of course, meant that the dilators 
were always needed ; but their particular value appeared in those cases where 
but for their use mere temporary measures had to oe adopted until the os had 
sufficiently dilated to permit of operative procedure, and so possibly lead to a 
delay that might prove fatal. 

Zir Oldham also agreed that it was important to take steps at once in any 
case of placenta prsBvia to accomplish delivery — a plan, he thought, admitted 
by most practitioners in London, and one upon which he had uways acted. 
However, to effect this object, he believed that nothing was more easy or 
MiisfactOTY than to turn b^ the plan recommended bv Dr Braiton Hicks, and 
to bring oown the child mto the os. He (Dr Oldham) had only the night 
before a case where its application was most satisfactory. He considered the 
plug, which had been recommended for many years, might be used where the 
cervix was very rigid, and preventing the introduction of the finder ; but its 
chief advantage was as a provocative of labour, and he doubted if it would be 
equal to stop nsemorrhage. 

Dr Qreenkaigh stated in reply, that he was very pleased to learn from the 
several speakers that in these cases they had, one and all, adopted the plan of 
earlv delivery advocated in his paper, and mostly with satisfactorf results to the 
mothers, which he maintained was not the course recommended m the standard 
treatises on midwifery or pursued by practitioners in general. He believed 
that the great success to the children in his cases was mainly due to not sepa- 
rating either a part or the whole of the placenta from the uterus, to retaining 
the membranes intact until dilatation of the parts had been effected by the 
pains and plug, and by avoiding version in cases of head presentation, which 
entailed more or less risk upon mother and child. He was quite convinced 
that with these precautions a premature child, whose head was small and easily 
compressible, stood as good, if not a better chance of being bom alive than a 
child at term. In allusion to the plug, he stated that some years ago, as 

VOL. X.— NO. ui. 2 m 



268 PBBISCOFE. [S£PT. 

ntentioned in hie paper, he had used on inflated india-rubber bag, bat had 
found it inefiiBctual in arrestiag the flow of blood from the vagina, which be 
had never failed to control, no matter how levere, with the spongio-piline plug. 
He conndered the effects of the ping to be as follows : — 1st, To prevent the 
escape of blood from the vagina ; 23, To fiivoor its coM^tion in the npper 
part of that canal ; Sd, To excite uterine action ; andj 4t^, To dilate the 
passages. The author approved and adopted the practice of rapturing the 
membranes in 8lip;ht cases of pifrtial placental presentation, and of taming 
m certain mal-positions of the child ; but he said that he had not alluded to 
this class of cases in his paper. Dr Barnes having stated that the statistics 
of Dr Read were not trostworthy, and that the author of the paper had 
estimated the mortality to the mothers too high, Dr Greenhalgh urged in 
confirmation the results of the practice of the Dublin Lying-in Hospital, and 
of his own early experience in cases of placenta previa. In conclusion, he 
trusted that after the expression of opinion of so many eminent accoucheurs, there 
could be no doubt whatever as to the propriety of early delivery in these cases, 
upon which the ultimate safety of the mother mainly depends. — The Lamed, 

CASE or CESAREAN SECTION — ^BISTU OBSTRUCTED BY ENORMOUS HYDATID 
CYST OF LIVER. BY DR MICHAEL THOMAS SADLER. 

On the evening of 26th April 186d, I was reouested by Mr BUckbum of 
Eamsley (who was confined to his bed by severe ulness) to see Mrs S., residing 
about two and a-half miles from Bamsley, and who had been for some days in 
lingering labour under the charge of his assistant. 

The patient was twenty-one years of a^e, about nine months pregnant with 
her first chUd ; she was a little under the average height, and had from an 
early age a remarkably protubcmnt abdomen. 1 found that there had been 
an escape of liquor amnii on the morning of the 19th, and ever since that time 
there had been from time to time violent pains for brief periods followed by 
long intervals of repose. On examininj^ per vaginam, I found that I could 

Sit reach the ob uteri by passing my finger up a narrow passage between a 
rd prominence in front of the sacrum and the pubes ; the os was undilated, 
nndilatable, and flattened, and the head could be just reached within it. The 
pulse was about 80, and there were no signs of approaching exhaustion, and 
as a medical friend, who had seen the case before, thought that there had 
been some little progress, we determined to wait until morning, and then to 
have a further consultation, leaving her in the meantime in charge of an 
assistant. 

Next morning, finding that there was no improvement, I got two medical 
friends to see her with me. Bv this time her strength was fli^^ng, the pulse 
had risen to 150 and was smaU, an offensive discharge was begmning to flow 
from the vagina, and the parts felt hot and unhealthy. They agreed with me 
that it was (juite necessary to deliver the woman at once, and, at the same 
time, that delivery by the natural passages was impossible, as only two fingers 
could be passed between the pubes and promontory of the sacrum, and even if 
we had succeeded in perforatmg the cranium of the foetus, it would have been 
impossible to have got the fragments through the brim of the pelvis. The 
obstructing protuberance was excessively hs?d, and had all the characters of 
a large exostosis of the sacrum. The space between it and the pubes was 
about an inch and a quarter. After much anxious deliberation it was decided 
to perform the Csesarean section, which I accordingly did with the assistance of 
Mr Stawman, Mr Harrison, and Mr F. Churchill. Having emptied the bladder 
and rectum, I made an incision from a little below die umbilicus along the 
linea alba to the pubes, and cautiously opened the abdomen, when a large mass 
of apparently mesenteric disease came into view above the uterus, and which, 
through the integuments, had felt remarkably like the head and limbs of a 
child. The uterus was opened rather to the left, to avoid risk of injuring the 
bladder, a quantitv of thick yellow liquor amnii was carefully sponged out, and 
a dead child of fuU sice removed, and after that the placenta and a quantity of 



16C4.] MIDWIFBRT. 269 

meconinm. Having Mcertained thai the vtamii wai perfsctlT empty, and 
iMviiig felt from abore the narrow antero-poeterior diameter of the bnm of the 
pelvis, the ateras beinff well contracted and all blood and elots remored, wa 
closed the wound with silver wire sutures and broad straps of plaster, and 
applied a bandage roond abdomen. At 7.46 p.m. the patient was sensible, 
me from nam, and desired to sleep. 

2Stk, 9.30 A.M.— Has slept well, and is free from pain. Has vomited twice 
since last evening. Pnlse 130, feeble. Moderate discharge from vagina. A 
few drops of urine were drawn off by the catheter. Stimulants, beef-tea, etc, 
were taken during the da^, and at 8 p.m. there was not much change. She 
died, however, ab^t midnight, still sensible and free from pain. 

With great difficulty, permission was obtained from the friends to re-open 
the wound and examme the body as far as possible without enlarging tha 
aperture, but nothing more was to be done. The first thing that attracted 
attention on opening the abdomen was the appearance of a semi-transparent 
round body about the size of a krge mu-Ue, roIUnK about among the intestines ; 
these rapidly mnUiplied, and we soon found that tne cause of aU our difficulties 
had been an enormous cyst filled with these hydatids, occupying the whole 
upper part of the abdomen in the region of the liver, and extending downwards 
au)ng the spine to the pelvis, and so compressed by the pressure of the uterus 
from above a^ to assume a degree of hardness simulatiog that of a bony growth 
from the promontory of the sacrum. 

Of course it is easy to see now that the best course would have been to have 

gassed a trocar into the supposed bony obstruction, for though no quantity of 
nid could have escaped by the canula, yet the non-bony nature of the growth 
would have been demonstrated, and we might possibly have been able, bv as 
incision through the VHgin&j to have let out a siuBcient quantity of the hyaatid 
growth to have allowed the child to have passed through the pelvis, and so 
might have given the poor woman a very slightly better chance of her life than 
was afforded by the dreadful iJtemative of the Cswurean section. I have thought 
it my duty, however, to publish the case, as it is, as far as I know, unique, and 
may not be the less useful to my fellow practitioners for being unfortunate for 
the patient and unsatisfactory to myself. — Medical IHmes and Gaaette, 

THE TEEATMENT OF LAGERATIOM OF THE PERIN JSUM INTO THE RECTUM 
DURINQ PARTURITION. BY DB T. ROBINSON. 

In the Medical Times and GaaeUe^ August, 1861, 1 drew attention to the suc- 
cessful treatment of severe laceration of the perinteum and^ rectum by simple 
means, adapted to retain the parts in undisturbed approximation, and allow 
union by first intention. Subjoined is another instance of the success of this 
plan. In this case the rectum and vagina were made one large opening, the 
rent, two days after the accident, being several inches in length. 

The subject was a primipara, aged 30 years, with a vagina so small that the 
conjugal rite could not be consummated until artificial means to dilate it had 
been resorted to. At the full period of gestation labour came on, and after 
twenty hours of steady natural uterine action a lacge dead child was bora* 
The vasnna preserved its integrity during the passage of the head, which was 
very soft and pliable, and of low temperature. Death had occurred probably 
a few days before. The shoulders were delayed some time on the fourchette, 
and at length suddenly expelled by a violent uterine effort, laying open the 
vagina into the rectum to a most formidable extent. On the second day, 
observing that fsecal matter had passed through this recto-vaginal opening, I 
cleared out the intestines by an aperient, and afterwards gave opium, and 
adopted a limited diet containing very tittle solid matter — so that the descent 
of faeces into the rectum might be retarded,— and having washed the parts free 
from flJl excrementitious matter, I bound the knees together, and desired the 
patient strictly to avoid all movement of the lower half of the person, to main- 
tain the psrts undisturbed. This plan was pursued during eignt days, when a 
general union was apparent ; an enema to unload the bowd was given, and the 



270 PERISCOPE. [sept. 

patient allowed to get oat of bed. From this time she might be considered 
recovered ; the parts have continued sound and whole to the present date — a 
period of two months. 

That laceration of perin»um, short of implicating the rectum, is a common 
accident, and may be left entirely to nature with wfety, is an axiom in mid- 
vdfery, substantiated by daily experience; and I wish to impress that very 
extensiye injuries opening up the rectum may be cured by adopting means to 
prevent the torn surfaces bemg disturbed, and to induce healing by first inten- 
tion. The means for attaining this object are, first, keeping the patient for 
several days on food containing very little solid matter, which in its descent 
into the rectum would disturb heabng; secondly, opium daily to constipate 
the bowels ; thirdly, by preventing movement of the lower limbs as mncn as 
possible. At first the knees should be bound together. Patients become very 
weary of this after two or three days, and it may be discontinued, as was done 
in the above and other cases I have had — it bemg forcibly impressed on them 
that they must not separate the thighs, — cautious flexion is not hurtful. 

Should these means hily we can then have recourse to " paring and stitching," 
with the usual chance of success. — Medical Times and Gazette. 

ON IODIDE OF POTASSIUM AS AN ANTELACTESCENT. BT FREDEBIC H. MORRIS. 

It was in consequence of the unsatisfactory results obtained from the external 
application of belladonna, in. arresting the secretion of milk, that I was induced 
to try the internal administration of iodide of potassium, first recommended, I 
believe, by M. Roussel, of Bordeaux. 

I have resorted to its use in upwards of a dozen cases, during the last ^VQ 
years, where it has been advisable to arrest the secretion — e.g. where the child 
has been still-bom, or has died a few days after birth ; where, from sore nipples, 
injury to the breast from prior abscess, or from some accidental cause, conges- 
tion of the breast has been set up, and lacteal abscess threatened, — ^and in no 
instance have I been disappointed, even when belladonna has failed to afibrd 
relief. 

The following case may serve as an illustration : — 

Mrs R. was confined of her first child on the 25th of December 1863. The 
child, a weakly infant, died a few days afterwards from atelectasis puhnonum. 
The breasts of the mother became tumid and painful. Extract of belladonna 
mixed with glycerine was applied round the areola for two days, when the 
pupils became dilated, without, however, any relief to the breasts. The patient 
was feverish and restless ; the breasts were tumid and painful, and exhibited 
every appearance of speedjr suppuration. Three grains of iodide of potassium 
in a saline draught was given every four hours, and five grains of Dover's 

Eowder at bedtime. Next day the breasts were less swollen, and she expressed 
erself as feeling much better. In the course of three days all tumefaction had 
subsided, and she discontinued the medicine. 

The plan I adopt is to give three gnuns of the iodide in an ordinary saline 
dratu^ht every three or four hours. In from twenty-four to thirty-six hours 
the fever ana engorgement have ceased, and in from two to three days all 
tumefaction has suDsided, even where abscess seemed unavoidable. — The 
Lancet. 



1864.] HEDIGO-CHIRUBaiCAL SOCIETY OF EDINBURGH. 271 



$art iFottrtl. 



MEDICAL NEWS. 
MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH. 

8E8BION XLin.—UEBTIMa IX. 

Gth July 1864.— Professor Douglas Maclaqan, President of the Society, 

in the Chair. 

I. CASES OF DISEASE OF THE TRICUSPID VALVE. 

Dr Haldane exhibited two hearts, in both of which there was a morbid state 
of the tricuspid valve. 

The first specimen was obtained from the body of a woman, thirty*eight 
years of age, who was admitted into the Royal Infirmary about the middle of 
March, in a state of great oppression, and suffering much from difficulty of 
breathing. The face was oedematous and of a dingy colour, the conjunctiva 
had a yeUowish tinge, and there was considerable general anasarca. The sur- 
face was cold, and the pulse scarcely perceptible. Having been somewhat 
revived by the application of heat and the administration of stimulants, she 
stated that she had never been very strong since she was fifteen years of affe, 
when she had measles, followed by rheumatic fever ; of the latter disease she 
had had two subsequent attacks, and for many years had been unable to make 
any unusual exe